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Medicaid Managed Care

Iowa's Medicaid program is managed through three managed care organizations: Amerigroup Iowa, AmeriHealth-Caritas Iowa and UnitedHealthcare Plan of the River Valley. IHA has created this Web page as a resource for hospitals as they work with these organizations and serve Medicaid beneficiaries.

Recent News

DHS Releases Medicaid Managed Care Quarterly Report

The Iowa Department of Human Services released a new quarterly reports providing data and insights into the ongoing transition to Medicaid managed care. The 87-page report contains newly promulgated data from October-December 2016. 

The report includes updated enrollment data showing the split of Medicaid beneficiaries across all three MCOs, showing total MCO enrollment at 605,700 during the quarter. 

From an enrollment perspective, the data shows that Medicaid beneficiaries are switching MCOs less frequently with only 4,300 members changing MCOs during this reporting period (compared to 4,800 in the previous quarter and 15,000 during the first quarter of implementation).

While there have been some areas of improvement over the past quarter, MCOs continue to report high call volumes from members and providers.  The contract requires 80% of provider helpline calls to be answered timely, and each MCO is modestly above that threshold with Amerigroup reporting 81 percent, AmeriHealth-Caritas 86 percent and United 88 percent.  However, this still means that approximately 20 percent of inquiries from providers are not being responded to in a timely manner, or the call was abandoned.

The report also details the top reasons for claims denials across all health care providers.  Reported denial reasons include:

  • Duplicate claim
  • Prior authorization requirement not met
  • Patient ineligible to receive service
  • Claim filing time limit expired
  • Additional documentation requested
  • Expense occurred after coverage terminated

Finally, the report provides some detail with regard to the financial condition of the MCOs.  Amerigroup reported the largest loss across the quarter at -27 percent, AmeriHealth-Caritas and United also reported negative margins at -16.6 percent and -11.6 percent respectively.

At a recent legislative committee meeting, the MCOs admitted that there are areas that need improvement but committed to continue discussions with providers.  While it is not clear whether or not the state will need to appropriate additional funds to the MCOs they estimated a combined loss of $450 million in the first year of managed care.

To view the full report click here

To access previous reports click here.

ER Recoupment Causing Issues for Hospitals

IHA continues to hear concerns from hospitals that have received recoupment notices from Medicaid Managed Care Organizations (MCOs) regarding claims originating from the emergency room (ER) that contain billing codes that are considered “non-emergent.”

The following Iowa Medicaid Enterprise (IME) informational letters describe the evolution of this policy which passed by the Legislature 2011.

Hospitals have indicated that the list of ICD-10 codes being used to determine this recoupment is incomplete and inaccurate and does not include a number of codes that are used in the ER, particularly those related to behavioral health. IHA has learned that IME is aware of this issue and will be providing an updated code list to MCOs.

AmeriHealth-Caritas inadvertently post-dated the letters received by hospitals, thus shortening the amount of time to respond to or contest the recoupment request. Several Critical Access Hospitals reported that they received letters on or around March 31, with the letter dated March 17 - with 30 days from the date of the letter to respond. AmeriHealth-Caritas has extended the deadline for hospitals that received letters during that timeframe, until May 27. Any hospital that is approaching a deadline and still needs more time should reach out to their MCO provider representative and request an extension.

IHA will continue to monitor this process and provide more information as it becomes available.​

State Resources

Medicaid Modernization Homepage (Iowa Medicaid Enterprise)

IHA Positions and Analyses

2016 IHA Medicaid Managed Care Principles (April 1, 2016)

Webinar Video - Contracting Considerations for Hospitals - Martie Ross, principal for Pershing Yoakley & Associates, PC in Kansas (November 5)

IHA Medicaid Managed Care Policy Update Webinar - Slides (November 4)

IHA Question and Answer Memo on Rate Setting and Provider Networks (October)

IHA Guest Column: Medicaid Privatization Undermines Innovation, Access (October)

IHA Talking Points on Medicaid Managed Care (August)

IHA Comment Letter on Federal Waiver Documents (August)

IHA Talking Points on Federal Waiver Documents (July)

IHA Comment Letter to DHS (June)

IHA Managed Care Principles (June)

Managed Care RFP Issues for Hospitals (June)

Medicaid Managed Care Background

Medicaid Managed Care In Iowa (Medicaid.gov)

2012 Medicaid Manged Care Enrollment Report (Medicaid.gov)

Medicaid Managed Care: Key Data, Trends, and Issues (Kaiser Family Foundation, 2012)

2016 IHA Medicaid Payment Policy Workgroup 2

2016 IHA Medicaid Payment Policy Workgroup 1