December 01, 2023

Local agencies prep for Medicaid transition

Directors with several organizations say there are many unknowns

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Even some of the strongest proponents of the privatization to three private Medicaid managed care organizations don’t talk about it with the smiling enthusiasm shown for other issues. It’s simply state mandate.

Meanwhile, in care facilities in Jasper County and across the state, care providers, hospitals, clinics and various health care agencies are getting ready to make the switch to one of the three MCOs — UnitedHealthcare, AmeriHealth Caritas Iowa and Amerigroup — chosen to contract with the state of Iowa. There are many unknowns and seemingly millions of questions to answer, but the April 1 transition is the next big step in the process for the 560,000 Iowans affected.

Jasper County organizations that deal primarily with mental health issues are hoping the transition goes more smoothly than their directors fear.

Connie Wright, program director of Optimae Life Services of Jasper County since it opened in the summer of 2011, said there are many unknowns, but her organization has tried to ask questions and answer as much as it can ahead of Friday’s transition.

“We feel we’ve put ourselves in the best position we can, as far as information about what will change,” Wright said. “There is just so much we won’t know until we go past April 1 and see what challenges come up as we go.”

One challenge Wright described, for example, is pre-authorization of services. MCOs will not always pre-authorize certain services prior to a patient being eligible, so for clients affected by this dilemma, April 1 can’t really get here fast enough.

The Medicaid privatization, touted by Gov. Terry Branstad as a way to save billions of dollars annually in state funds, was challenged on several levels. A short-lived bipartisan legislative bill to cancel all contracts, and two federally ordered delays of the transition date were among the efforts. However, all the noise about when the transition will happen has transformed into which client services will be affected, and how each one will see a difference in care.

Optimae has about 110 clients in its community program and many more who seek regular or occasional treatment services.

Melissa Butler, communications director for Progress Industries, said the 200 clients the nonprofit serves at its Newton facility have had concerns about whether they’ll be able to continue with the same case manager and other care staff. PI personnel have worked diligently to answer as many of those questions as they can.

“One of our goals is to make all transitions, including this one, as seamless as possible,” Butler said. “Empowerment is a concept we discuss a great deal, and we try to involve people in their own decisions about their care. So once we were able to get some more detailed information about this transition, the privatization became more abut helping clients make choices and stay informed.”

Julie Smith, executive director of Capstone Behavioral Healthcare in Newton, said her organization is credentialed with all of three new MCOs for the services, but this change affects every aspect of medical and mental health services.

“We are supposed to be able to provide the same services, and receive the same reimbursement for patients until the end of 2017, as a community mental health center,” Smith said. “We will now have to learn how to bill three different entities, as opposed to one. The transition from Magellan to IME was unbelievably difficult. It is my hope that the transition to the MCOs will be a smoother transition. The MCOs’s have reached out to us, offering training and support with all aspects.”

Laurie Doyon, Progress Industries’ vice president of operations, said the process involves clients/patients selecting one of the three MCOs based on needs. For example, one MCO might bill differently, cover services in different ways or have contracts with specific providers in a given geographic area.

“We cannot influence or advise anyone on which MCO to pick,” Doyon said. “We simply direct them to resources and people who can answer their questions. Initially, their questions were more general, like are we still going to be here in this building, and we said, yes, we’ll still be here. But as time went along, we got more specific questions, such as whether a client can keep a case manager.”

That particular question, like many others, is answered by whether each provider or agency decided to sign a contract with a particular MCO. For example, if a Progress Industries client’s case manager signed contracts with both UnitedHealthcare and AmeriHealth Caritas Iowa, but not with Amerigroup, and a current client decided to choose Amerigroup, the client would have to develop a relationship for a new case manager — a more daunting task for some than others.

“It’s been tough to explain some elements of the transition to clients or their guardians,” Doyon said. “But, really, all new partnerships are about challenges and streamlining, and ultimately, it’s about outcomes. Some of the business side of this was tough at first, especially before many contracts (between care providers and the MCOs) had been signed, but we feel we can still bring quality care without interruption.”

Smith and Wright both said one dilemma is none of the three companies are not familiar to most Iowans. Fortunately, if Iowans are unhappy with their first choice and want to select a different health plan, members can continue to make changes in MCO selection for any reason until June 16. After that date members can only make changes in MCO selection for “good cause’” such as a provider hasn’t joined the MCO network.

“The first thing that I am concerned about as the director is being able to get services authorized for patients,” Smith said. “We don’t want anyone to go without care, prescriptions, etc. That is Capstone’s priority. As a provider, we also have to be concerned about the ‘behind-the-scenes’ changes.”

If a Medicaid client does not choose an MCO from the options provided, the state will assign that person to one of the three MCOs. Karen Sallis of Integrated Treatment Services said many of her organization’s 80 to 100 clients have already been notified they’ve been assigned to one of the MCOs, but not many had received their insurance cards as of Monday.

“There is probably more that is unknown than is known,” Sallis said. “Not only do we need to wait until April 1 to discover how to bill each of these companies instead of the state, but we even had trouble making sure our contract with each MCO was finished. In one case, an employee moved on from her company without telling anyone that one document was missing for our contract to be complete.”

Smith said April 1 really might mark a beginning — the time when providers discover how the system works on a daily basis and what needs to be fixed.

“It is going to be very confusing for the patients during the transition, especially if their current provider is not contracted with a particular MCO,” Smith said. “The unknown is very difficult for a lot of people. Change is difficult, and hopefully, this change won’t affect how people can get medical and mental health treatment.”

Contact Jason W. Brooks at 641-792-3121 ext. 6532 or