H&W hears concerns on multi-year managed care transition

REXBURG — A Monday panel on Idaho’s Medicaid transition was largely characterized by discussion of the future administrative burden faced by health care providers and the varying uncertainties among Medicaid recipients about the growing role out-of-state parties will have in the administration of in-state services.

The Idaho Legislature’s Medicaid Review Panel’s meeting at Madison Health Hospital in Rexburg was one of several regional stakeholder listening sessions that will be taking place across the state through May of next year as the Idaho Department of Health and Welfare seeks feedback on its change in how Medicaid functions in the state of Idaho.

Idaho previously administered Medicaid through the traditional fee-for-service system where the state directly contracts with and pays health care providers a fee for each service provided, such as an office visit or procedure, to a recipient of Medicaid. That is changing with this year’s passage of House Bill 345, that implements a new Medicaid framework known as managed care.

Under the new managed care system, Idaho will use third-party contractors to administer Medicaid benefits and provide oversight for the system. These third parties, known as managed-care organizations (MCOs), will take responsibility for paying health care providers and coordinating care, and, to keep costs down, will be emphasizing preventative care to avoid more serious medical benefits that burden the limited resources of Idaho’s rural hospitals and community clinics, according to the legislation.

FULL TRANSITION IS YEARS AHEAD, BUT BEGINS SOON While Idaho has a few MCO contracts at present, this would mark a comprehensive transition to a managed care operation.

This transition will be years-long and the IDHW will take a “phased approach” to the transition that will see most Medicaid programs under managed care by Jan. 1, 2029. Developmental disability services will be operational under managed care two years later, in January 2031, Sasha O’Connell, IDHW deputy director and state Medicaid administrator, said.

While this feels far-off, O’Connell said the department will be writing requests for proposals to third-party administrators to organize competitive bidding for the third-party administrators by October of next year with contracts being awarded in May 2027. In total, the beneficiaries will be able to choose from three different plans, which have yet to be finalized.

With this in mind, the department is now seeking input from Medicaid beneficiaries from across the state as the transition gets underway to compile their hopes and concerns about the transition, their issues with Medicaid and the desired improvements for the health insurance system. The panel of state legislators provided attendees, consisting of both health care providers and Medicaid recipients, the opportunity to do just that.

Tara Rowe, a Twin Falls resident, described herself as a recipient of Medicare and Medicaid with a complex chronic illness. Her biggest concern, she said, was contracts with MCOs that leave health care services up to interpretation without clear definitions. She said the issue currently presents itself with the ambiguity around what a care coordinator is.

Rowe said the lack of a defined care coordinator — which typically connects patients to resources and communicates with several providers — resulted in her having a nutritionist, a care navigator through a federal community health center, a pharmacist consultant and a temporary provider to manage her health needs.

“Those are four additional providers that the state of Idaho’s Medicaid now pays for, rather than the care coordination that is supposed to be part of the plan as a managed care situation requires,” Rowe said. “I just feel that there’s a lot of waste in the system that could be avoided.”

Idaho State Senate Minority Leader Melissa Wintrow, D-Boise, followed up that care coordination has been a “frequent” and “consistent” complaint for those receiving Medicaid and noted the IDHW would have to define the position as well as outline a required number of care coordinators for those with complex needs.

O’Connell concurred, stating that the fee-for-service system does not provide the number of care coordinators needed to serve all Idahoans, providing an opportunity for MCOs to fill the gap not met by the state.

Sen. Kevin Cook, R-Idaho Falls, questioned whether the care coordinator would represent the patient or the MCO that employs the coordinator. O’Connell said that the arrangement was similar to a human resources position that represents employee interests, but acknowledged the “conflict of interest there” made “contract requirements even more important.”

PROVIDER CONCERNS On the financial side, meeting attendees also raised concerns about payment rates — the amount states pay health care providers for Medicaid beneficiaries — being too low as is and dropping lower under a managed care system.

Joann Goddard, who manages a certified family home, described how her operation has been challenged by the recent 4% cut in reimbursement rates for Medicaid providers in Idaho and questioned how sending money out-of-state would address the current tightening in the system.

Several others who testified voiced similar concerns, stating that these outside contractors often lack familiarity with the nuances of Idaho’s rural health care landscape. Laura Scuri, owner of Treasure Valley-based Access Behavioral Health, said MCOs are “not prepared to be in Idaho” and, instead of adapting, seek to transpose their existing model that could have been successful in another state, but is not bound to see similar outcomes in Idaho.

Speaking to past committee meetings on the transition, O’Connell said IDHW will be looking to respond to health care provider concerns regarding the coming administrative burden. For those that have only been paid through the previous fee-for-service model, they will have to consider whether they will want to enter into three different contracts for the the three different managed care plans, that will bring separate agreements and credentialing requirements.

For the Medicaid participants navigating these different plans, O’Connell said the hope is to collaborate with Your Health Idaho, the state’s health insurance marketplace, to post the managed care plans, providing a venue for comparison that already has infrastructure built out. The department is envisioning managed care using a similar open enrollment procedure, but there remains concerns about individuals who either don’t enroll in this window or otherwise have difficulty selecting from the available plans.

Using other states as a model, O’Connell said Idaho could be addressing this through the use of an enrollment broker that would evenly distribute people to one of the three plans available if they do not choose one on their own. For those seeking information on plans, the broker could also offer a call center to walk Medicaid participants through the details of the respective plans, though the details of such an arrangement have yet to be determined.

In a comment made earlier in the meeting, Wintrow described being “overwhelmed” by the focus on processes and administration that characterized IDHW’s initial presentation, and ultimately, the remainder of the four-hour panel.

“We’re not even talking about health care anymore and the concern is that going forward, we’re … creating all these categories for MCOs and different pathways for providers to try to get paid,” she said. “ … it feels like we’re spending all of our taxpayer dollars on administrative functions instead of actual health care.”