Meeting Minutes, August 11, 2008
Background. 2008 Iowa Acts, House File 2539, creates the Iowa Choice Health Care Coverage Advisory Council to assist the Iowa Comprehensive Health Insurance Association with developing a comprehensive health care coverage plan to provide health care coverage to all children without such coverage that utilizes and modifies existing public programs and to provide options for access to private, unsubsidized, affordable health care coverage for purchase for children and adults who are not eligible for public programs. The comprehensive plan must be submitted by the Association to the Governor and the General Assembly by December 15, 2008.
The advisory council consists of nine voting members, including former Governors Terry Branstad and Tom Vilsack, and seven members appointed by the Director of Public Health. The Council also includes seven ex officio, nonvoting members who are the Commissioner of Insurance or a designee, the Director of Human Services or a designee, the Director of Public Health or a designee, and four members of the General Assembly.
Overview. The first meeting of the Council was convened by Commissioner of Insurance Susan Voss. Former Governors Terry Branstad and Tom Vilsack gave opening remarks.
Presentations. Senator Jack Hatch gave an overview of House File 2539 and an update on a report being prepared for the Legislative Commission on Affordable Health Care Plans for Small Businesses and Families by The Lewin Group that estimates cost and coverage impacts of proposals to expand health insurance coverage in Iowa. Mr. Pat Carmody, President of the Iowa Comprehensive Health Insurance Association Board (commonly referred to as HIPIowa); Mr. Cecil Bykerk, Executive Director of the association board; and Mr. Bill Boyd, attorney for the association board, gave an overview of the association and its role in providing guaranteed-issue health insurance coverage to people who are unable to obtain health insurance coverage elsewhere.
Actions and Future Meetings. Ms. Carrie Fitzgerald, Child and Family Policy Center, was elected as chairperson of the Council, and Mr. John Aschenbrenner, Principal Financial Group, was elected as vice-chairperson. Chairperson Fitzgerald indicated that the council would hold at least two half-day meetings each month to prepare recommendations for consideration by the Association for inclusion in the comprehensive plan that is due in December.
Advisory Council Contact. Information about the Iowa Choice Health Care Coverage Advisory Council can be obtained from Insurance Commissioner Voss at (515) 281-5705 or susan.voss@iid.state.ia.us.
LSA Monitor: Ann Ver Heul, Legal Services, (515) 281-3837.
Welcome and Introductions
Chairperson Fitzgerald called the meeting to order at 1:30 P.M. on Wednesday, September 3, 2008. Present were Fitzgerald, Aschenbrenner, Griffin, Teeling, Hatch, Seymour, Heddens, Titus, Newton, Laue and Brewer. Voss was represented by a member of her staff. Vilsack, Branstad and Knaack-Esbeck were absent. Cecil Bykerk with the Iowa Comprehensive Health Association Board attended by conference call. Guest speakers Gene Gessow and Ann Wiebers of the Department of Human Services also were at the table to make presentations on the Hawk-I and Medicaid programs.
Review of Council’s Work
A motion to approve the minutes of the LSA summary meeting of was made by Laue. The motion was seconded by Hatch and passed. Laue noted that the scheduled topics dealt with covering children and asked if the scope of the group’s mission was broader, and should include coverage for adults under the provisions of HF2539. Aschenbrenner responded that the eventual impact of the legislation was to go beyond coverage only for children, but that the limited time available prior to the Advisory Council’s recommendations to the Iowa Comprehensive Health Association made a narrow focus of this phase necessary. Hatch agreed and indicated adults would be considered in a later phase within the format established by coverage for children.
Information on Current Programs That Cover Kids: Medicaid and HAWK-I
Gene Gessow and Ann Wiebers of the Department of Human Services then made oral presentations covering written information they had distributed to the Council as an explanation of how HAWK-I and Medicaid cover segments of the population of children, state and federal sources of funding and the criteria used for determination of eligibility for each program.
Members of the Council had several questions and learned from the presenters that poverty level guidelines used in benefit determination are based on net income after an income disregard, that for some children in institutional care the income of the child is the figure used instead of the income of the parent, and that the poverty level used could be a higher figure if not for the current administration’s resistance to that idea.
Hatch asked if recent decisions by the federal government meant that the restrictions on the poverty level cost share allowed by the federal government had been rescinded. Gessow explained that the recent actions constituted a reinterpretation rather than a rescinding and that changes in sharing of funding based on higher poverty levels was not likely in the near term. He speculated that Iowa and other states may seek expansion of federal sharing of Medicaid costs based on poverty level early in the term of a new administration.
Gessow pointed out that different states fund assistance differently, and that some states provide funding for certain income levels beyond those where federal funds contribute as “premium assistance subsidies” providing partial funding for a family’s insurance cost. He also said that children eligible for SSI are automatically eligible for Medicaid. Further protection for children between 18-20 years old is called Child Medical Protection.
Hatch requested that a summary of all the programs that apply to the coverage of children be completed and presented to the Council. He asked about waiting lists that keep children from getting on coverage. Gessow explained that some coverage is mandatory and some is optional, and described circumstances in which a waiting list might apply and others in which the waiting list would never occur, as well as the process for moving up on a list. He reminded the group that Medicaid is an entitlement program and that there are ways to qualify by health status without regard for family income.
Griffin observed that the circumstances of coverage are broader under HAWK-I and Medicaid than is the case in a private insurance model and wondered how the model for coverage should be established and how the private model might come into play. Gessow responded that Medicaid is a payer of last resort, so coverage under a private plan might serve as a base for a broader coverage accessible through Iowa Choices and observed that the private insurance model has itself changed over time. Heddens noted that the Health Insurance Premium Payment might have application as well. Fitzgerald agreed that all aspects need to be kept in mind and considered.
Wiebers said that the vendor providing the benefit eligibility administration of the program was changing from Maximus to Policy Services, Inc. on January 1, 2009 after a competitive bid process. Claims handling is done by the health companies instead of this contracted third party administrator.
Wiebers and Gessow both addressed the question of the number of children of undocumented residents of Iowa, admitting there is no clear answer. Gessow said there are some reported services that can provide an approximation, but the nature of the situation of these children makes it impossible and possibly unwise to attempt to identify them. There are surveys that might be useful. Seymour said he thought that the hospital association attempts to track information about treatment given to undocumented children that might be useful. Hatch said he believed that in light of Gov. Vilsack’s prior comments, the group should attempt to determine an estimated number of children of undocumented workers in Iowa and an estimated cost of providing that coverage.
Wiebers next moved to the question of the cost of expanding existing programs to cover a broader population of children. The handouts showed estimated costs. Gessow said that the material had been drawn from some other separate sources and had some inconsistencies. He said he could get more information on a hypothetical overnight switch to a new system covering all children up to 300% FPL gross income.
Wiebers next addressed Medicaid cases closed, in which some children who were at some time covered left coverage. This is an area where there is not follow up of all individuals who leave, so it is unknown if they have simply moved, gotten jobs that make them ineligible because of income or other circumstances of loss. Some, she speculated, may leave because of the “hassle factor” of reporting requirements. Hatch spoke of the patchwork of possible coverage and the variance in eligibility requirements that make the program seem cumbersome and difficult to stay with. Gessow added that some move from these programs to insurance that covers less broadly. Further, he said that determination of Medicaid eligibility provides 3 months retroactivity upon determination of eligibility for payment of benefits received. Wiebers said that effective July 1, children are who are eligible keep their eligibility for a year. Heddens said it would be nice to know why people go off coverage. Wiebers agreed to ask Anita Smith to help get those answers.
Wiebers then discussed outreach and advertising of program eligibility.
Gessow said the programs include dental, but the HAWK-I program chosen determines the actual dental plan issued. Fitzgerald mentioned the inability of families who actually have private medical coverage to enroll in just the dental component owing to federal restrictions.
Griffin mentioned that there were sometimes issues when a new HMO or managed care plan opens in an area in changes in enrollment. Gessow said that benefits are the same, but providers approved for a network could change, with some loss of access to continuity of provider connections.
Review of Issues Related to Covering All Kids
Aschenbrenner expressed interest in getting some specific information for future meetings. Complete background needed by the Council would include: efficient enrollment process that could be used for HAWK-I and SCHIP, what the costs will be, sources of funding, a review of the benefits of each program, information about possible use of subsidies for private insurance premiums and how to get around barriers such as pre-existing conditions waiting periods for those using private coverage. Also, he sees the need to determine what benefits need to be included as covered and what population of children (age) are we attempting to cover. He also asked if this was to be tied to a medical home, and indicated that he personally strongly supported that idea. Another key question is the voluntary or mandatory enrollment of children. Finally, he said the interrelation of all the modes of coverage needs to be addressed.
Discussion and Additional Questions for Follow-up
Griffin asked about situations in which the parent of a child has coverage for the child available through the parent’s employment, but the parent chooses to not add the child to his or her coverage. Aschenbrenner said he did not believe that people were to be encouraged to leave the private market to get coverage. Teeling suggested finding ways to eliminate barriers for entry into various approaches might simplify the task. Hatch said this was why the program was called Iowa Choices, so that different people could have as many public and private choices as possible, both for children and eventually for adults as well.
Teeling returned to the question of closures, or people leaving programs, and asked about whether the people who left could be contacted to find out why they did so. Titus suggested that a sampling could be done. She wondered if insurance industry members of the Council might have an insight as to why people might leave coverage. She speculated that for some it might be what is perceived by some eligible families as a “hassle factor” of requirements. Aschenbrenner said income variations could come into play and that some have an inability to return to private plans.
Hatch suggested that subgroups considering various topics should be assigned in the few days following the meeting with a reporting requirement for the next meeting. Aschenbrenner said he hoped subgroup suggestions could be wrapped up at the following meeting and not have to be revisited after that in future meetings. Aschenbrenner then asked Council members to contact him or Fitzgerald regarding their interest in serving on particular workgroups. Fitzgerald and Aschenbrenner will get assignments to members.
Fitzgerald said that Medical Home applies to Medicaid, but not SCHIP. Gessow said that Medical Home is mostly related to the physician who decides to be a medical home, with that decision representing a sweeping change affecting all of his or her clients. Newton spoke of different sets of groups in Medical Home settings, with different reimbursement incentives. He said possible additional funding might occur soon and those changes would be posted to the web site.
Future Action Items
Hatch agreed to work with DHS on the question of who is covered and who is not. Aschenbrenner asked Gessow for help in determining the possibility of expanding federal programs.
Hatch spoke of the need to establish a subgroup looking into the transition from consideration of coverage for children to one that included adults as well.
Fitzgerald called on the Insurance Division for a report on the establishment of an Advisory Council web site. Tom Alger announced that a domain name was now registered but not yet operational. The plan is provide a site on which information about HF2539, a list of Advisory Council members, meeting notices, meeting minutes, written information submitted to the Council, and recommendations of the Council could be posted for members and the public. He estimated the site would be active within a week and offered to contact the Chairperson with that information and instructions for locating the site.
The meeting was adjourned at 4:00 P.M.
Introductions/Approval of Minutes
Chairperson Fitzgerald called the meeting to order at 1:35PM. Present were Fitzgerald, Griffin, Patterson (Newton), Wiebers (Titus), Boston (Voss), Laue, Teeling, Hanson (Aschenbrenner), Heddens, Hatch, Brewer. Governor Vilsack participated briefly by telephone.
Laue made a motion to approve the September 3, 2008 minutes. Griffin seconded the motion. The minutes were unanimously approved.
Follow-up items from DHS
Iowa Medicaid-Anita Smith and Gene Gessow were present to clarify information from the last meeting and to address any follow-up questions. Smith is the Bureau chief of Medical Supports responsible for policy development relating to Medicaid eligibility, administers hawki-i program, the health premium payment program for individuals on Medicaid. Smith and Gessow discussed the handout with attachments that outlined the Number of uninsured children and adults, type of care covered, how Iowa children qualify for Medicaid, strategies to keep people in Medicaid and hawk-i, financing/payment strategies, as well as an appendix on the number of children receiving or waiting for waiver services.
Number of uninsured children. Smith stated that the breakdown of the projected number of uninsured children in Iowa before the passage of HF 2539 was approximately 53,000 at all income levels. The number of insured kids would increase by an additional 29,856 due to HF 2539. Once reach 300% FPL and above no change identified for them because HF 2539 only extends kids up to 300% FPL. A strategy to cover kids at higher levels has not yet been developed. After HF 2539 is fully implemented the Lewin report projects about 23,000 children will be uninsured; approximately 3,500 kids will be under 300% of the federal poverty level. We can estimate that we will never have a 100% take-up rate if they are undocumented or do not qualify because of the five year federal bar against legal immigrant children. Griffin asked whether the 3,500 included undocumented children in the state. Gessow commented that the Lewin model assumes that there will always be those who are eligible but are not covered. The 3,500 does not include undocumented immigrants. Griffin sought clarification that part of the council’s charge included looking at undocumented immigrants. Fitzgerald put in a request to Pete Damiano (Uof I), Iowa Hospital Association and Iowa Export Center for information about the undocumented. Hatch clarified that there are four groups within our charge regarding children: those below 300% FPL that fall through the cracks, those above 300% FPL that choose not to have insurance, undocumented aliens, and legal immigrant children but not eligible due to the five year federal bar. Fitzgerald asked Smith what in HF 2539 increased enrollment so drastically for children under 200%FPL. Smith responded it was the strategies for presumptive enrollment, enrollment maximizations strategies and continuous enrollment.
Uninsured adults. The number of uninsured adults in Iowa is far higher than the number of uninsured children. 308,320 according to the Lewin report. Teeling asked whether that number included undocumented immigrants. Gessow replied that the number includes the number of adults who do not qualify for Medicaid because they are single, or a couple who no longer have dependent children. A certain percentage below 200% FPL would be eligible for IowaCare. Then the number includes everyone else in the population who cannot afford insurance or has not purchased insurance; about 10% of the population. The number does not include the undocumented. Types of care covered. The chart is a way to visually discuss the importance of distinguishing between insurance and receiving healthcare. For example, Medicaid and hawk-i cover preventative care, acute care; Medicaid covers restorative care, hawk-i covers some rehabilitative coverage, long term care typically not provided by hawk-i and private insurance. How children qualify for Medicaid. They qualify due to age and income, age income or disability. Smith explained that the department will be implementing the Family Opportunity Act on January 1, 2009 where children with disabilities qualify for Medicaid but are over income for SSI. Referring to chart in the handout Smith pointed out that as of July 1, 2009 the state will cover all kids up to 300%FPL. If a child is disabled, the child may qualify for Medicaid under the Family Opportunity Act, however, there are some resource and age limits. Under the Family Opportunity Act parents must enroll regardless of cost due to federal requirements. Level of care, some asset limits and age limits exists for some of the waiver programs. SSI eligible are for much lower income level parents (74%FPL).
Strategies for keeping people enrolled in Medicaid and hawk-i Smith said the department looked at the top 3 reasons to keep people from disenrollment and listed some of the strategies to keep people continuously covered. If a person disenrolls from Medicaid but comes back on later, coverage is retroactive for 3 months which is not true for hawk-i or private insurance. Top reason for Medicaid, family did not return review form, currently have a very short time frame ( 5-6 days) which is tied to all of the department’s public assistance programs (food assistance, TANF, FIP, cash assistance) where old practices that do not apply now determined how income had to be counted. Smith discussed a pilot program in Mason City to see what would happen forms were sent out earlier. There was a control group 5 days, and groups were the forms were sent out 10 days 30 days earlier. Found that the group receiving the forms 10 days earlier had a lower return rate than the 5 day control group. But those with 30 days had a much higher return rate. The department is looking at extending the time for returning forms and extending the time across all programs. Second reason was that the family failed to provide required information. Families can request additional time to provide information when needed. Third reason is because family is over income. HF 2539 implemented continuous eligibility. This allows children to remain eligible for the remainder of the 12-month enrollment period regardless of changes in circumstances. If the child is over income at renewal, they will continue to be referred to hawk-i. Five thousand children became eligible in July due to the combination of the disaster and continuous eligibility. As a result of continuous eligibility may not see as many kids being referred to hawk-i ; hawk-i numbers may stabilize. Reasons for disenrollment from hawk-i: The number one reason was that the family did not return review form hawk-i sends forms 60 days ahead of time, sends reminder postcards and letters, as well as two follow-up phone calls. Fifty percent of the families did not return form because the child had health insurance. Disenrollment is not necessarily a bad thing when the child has insurance. hawk-i tends to be a bridge for periods when children do not have insurance. The second reason is that the child became eligible for Medicaid. Family failed to pay premium was the third reason for disenrollment from hawk-i. Beginning in 2009 families will have the ability to pay premiums via automatic bank account withdrawal, credit card, or on-line. Laue wanted to know what happens to the other 50% of the families that did not renew. Smith did not have the chart with her but said some families simply forgot despite all of the reminders, but suspects that some just remain uninsured.
Financing/Payment Strategies-Smith stated that this morning the DHS council adopted the budget, reaffirming the $10M established in HF 2539 and efforts to maximize federal monies as much as possible. Iowa’s strategy is not to submit a state plan amendment until January when there will be a new administration. Hopefully there will be new direction at that time. If unable to get federal funding to expand to 300% FPL the department is prepared to use state only dollars. The group above 300% FPL presents the challenge and may look at subsidizing insurance and enhancing payments to regulated market. Gessow remarked that he was not certain why families above 300% FPL do not have insurance; whether they cannot afford it or they choose to self-insure. It is possible to create a subsidy or approach the problem of the cost of health insurance by creating a reinsurance facility to reduce the cost due to high risk people. Smith questioned whether those at 300%FPL and above consist of those who are self-employed where there is no cost sharing from an employer. Hatch posed a question to the council’s health economist (Aschenbrenner) in absentia. During the commission meetings Aschenbrenner pronounced that national association said if all were mandated to have insurance and everyone is treated alike certain issues like preexisting conditions would go away. Hatch asked if all children were in a pool would those same conditions apply to help lower premium. Secondly, the idea of subsidizing premium for families above 300% FPL would be difficult to bring to the legislature without significant data. How many families between 300-400%FPL exist? Hatch thought the Lewin report delved into this a bit. If there is a premium for this group it would be on a sliding scale. What incentives and whether a tax credit or tax deduction would be another acceptable strategy up to a certain point. Hatch pointed out that the commission did look at small business and it was an area of significant interest. Teeling stated that the Lewin report referenced 240,000 children, 11,000 without insurance. Griffin shared that the Federation looked at reinsurance and how much can you get the average small group rates down to make premium affordable. Her recollection was that it was pretty pricey to see significant reduction to see of 10-15%. Griffin explained that to guard against anti-selection insurers use pre-existing conditions, waiting periods and exclusionary riders. If there was an environment where all parents had insurance for children the use of those tools might be moderated. However, the underlying drivers of cost are challenging for private insurance and for the public programs.
Appendix: Gessow explained that 4,205 children were receiving waiver services. Hanson asked how long children are on waiting lists. Gessow stated that ill and handicap have the longest waiting list and it could be up to 24 months. The state has the authority to appropriate a limited amount funds and some waiver services are not funded 100%. Heddens sought clarification of information on the website which includes the entire number of those waiting for waiver services, including adults waiting for services. The chart in the packet includes only the list of those children that are waiting waiver spots. Of the 300+ children waiting for waiver services does not mean that they do not have insurance. It means that they do not have Medicaid. There were no additional questions or follow-up for Smith or Gessow. Hatch thanked the department for doing a great job and making the information very clear for the council. Hatch thinks the next direction for the council is to delve into the Lewin Report.
Prior to breaking up into small group discussion, Fitzgerald asked the groups to decide who will be the lead contact person. What the issues are within that topic. Report back to the large group what is needed to move your group forward. Report other reports or resources are needed. Discussion followed about this council’s access to the Lewin Report. Copies of the Lewin summary distributed at Des Moines University were made and distributed for use within the small group discussions. The Lewin report is also posted on the Affordable Commission website. It was suggested that the council review the Lewin report at the next meeting with the appropriate staff person to lead us in that discussion. It was also recommended that the Division put links to the commission report, HF 2539 and the Lewin report.
Patterson provided information about the seven advisory groups under the health reform bill and the availability of information on the department of public health’s website. The department hopes to convene first meetings within next month.
Fitzgerald announced about there was a good turnout at the SCHIP and Medicaid summit held last week with the Department of Human Services. As well as receiving good feedback, the group examined the legislation, discussed what to do to move forward, what the department is doing now, what other states are doing and what the federal government requires.
Laue asked about the rates and benefit design information from the high risk pool. Hanson offered to get the operational report for August from Cecil Bykerk. Laue mentioned that due to the small size of the groups that other with expertise be welcomed to participate in those discussions. Teeling expressed concerned as to how others were going to know what other groups were discussing. Fitzgerald said this is something that as a council that needs to be decided. Hatch stated that some of these answers will come to rather quickly. He suggested that the small groups meet today and resolve work quickly or decide whether to meet in between council meeting dates. Griffin imagines that because there will be a fairly limited number of policy decisions it may not be necessary to break into small groups.
The following groups met. Group 1 Benefit Review, Group 4 Maximization/Funding of Medicaid and SCHIP and Adults.
Wrap up discussion/Action items
Group 1 Report Griffin reported that there is a note taker and recorder but no chair). The group’s vision is that there would be a standard set of benefits which would be age appropriate and available for all children regardless of income or immigrant status. Need research on uninsured kids and their health status. That research might drive some specific health benefits for this population. For example, if obesity was higher among uninsured children the benefit plan might offer nutrition counseling or wellness benefits. Also need to compare benefits of Medicaid (without waiver services) and hawk-i as compared to state of Iowa benefit plan. This group would also look at maximizing parents use of employer sponsored insurance and options for parents to purchase incremental or additional benefits that might be outside the standard benefits plans (e.g. dental, vision, prescription benefits). The group would also want to know the cost analysis of those standard benefits.
Group 4 report Heddens stated that John Aschenbrenner is the chair. The group is looking at maximization of funding for Medicaid as well as presumptive eligibility. Need to explore ways to bring in more money and any potential impact on Title XXI. Pregnant women up to 200%FPL are currently covered. The group would like to ensure that that pregnant women up to 300%FPL are included so that coverage is compatible with other changes being implemented. The group will also look at the options for full cost buy-in to SCHIP. Group needed to hear from other council groups as to who is covered in the expansion to accurately determine maximization of funding.
Adults report Joe Teeling, Chair, Laue note taker. The group began its discussion about adults under 150%FPL. A discussion with the Feds and the congressional delegation to give states the option to expand Medicaid to cover those adults. For persons over 200%FPL , the group discussed different ways to give them access to coverage. Premium subsidies might be an example. Other items discussed included a mandate for employers to provide insurance, a separate pool for employees where the employer does not provide insurance, changing the small group size of a group from 2-50 to 1-50, treat insurance like education where there is no choice but to pay for it. Need information from other states as to buy-in information options.
The next meeting will be on October 1, 2008. Plan to review the Lewin Report. No report necessary from DHS. Griffin not available at next meeting will obtain another representative from Federation in her absence. Fitzgerald will try to convene Group 2- “What children” within the next week.
Meeting adjourned at 4:15PM.