Requirements for Iowa Medicaid Managed Care Contracts for Companies Serving Individuals with Brain Injury Managed Care plans typically receive a set of “capitated” payments from the State. This means that private companies get a set payment per person (Medicaid enrollee) in exchange for providing health care and/or disability services. In addition the private company typically assumes the risk of incurring a financial loss if it spends more on services than it has bargained for through the capitated (per person) payments. The company stands to make a profit if it spends less than it is paid for. Thus the incentive clearly exists for private managed care companies to limit access to, or attenuate the quality of, services in Iowa. To ensure the proper planning, design, and delivery of what may be the largest privatization in our state’s history, the following are critical components of a contracting process for Medicaid manage care contracts serving individuals with brain injury. Iowa Medicaid Managed care contracts must: 1. Maintain continued access to community-‐based neurobehavioral rehabilitation services (CNRS). CNRS are provided to Medicaid members who have sustained an acquired brain injury and are hospitalized, institutionalized, incarcerated or homeless or at risk of these situations. This service supports the member, their family, their caregivers and service providers in increasing the members adaptive behaviors, decreasing maladaptive behaviors, and adapting and accommodating to challenging behaviors to support the member to remain in their own home and community. 2. Exclude prescriptive caps for individual members monthly services for Home and Community Based services provided via the Medicaid Brain Injury waiver. The current cap of $2950 is NOT reflective of actual average costs. A significant number of members currently received “exception to policy” (ETP) designations. While this number may appear adequate in the “aggregate” it is unacceptably low as a cap for many individuals. There must remain a process to allocate funds to meet individual needs in the waiver system. 3. Address the current gap in community based services and supports for members with brain injury with specific plans to expand, support, reinvest saving in, and deploy community based services including plans and timelines for elimination of the current 30 month waiting list for Iowans Medicaid Home and Community Based Brain Injury Alliance of Iowa Requirements for Medicaid Managed Care Contracts for Companies Serving Individuals with Brain Injury in Iowa 1 4. 5. 6. 7. 8. Waiver for Brain Injury. Address and describe plans to support members with brain injury who are in out-‐of-‐ state provider locations. Address and describe plans to ensure level of care for members with brain injury in out of state placements or commensurate with the level of care currently available only in out of state placement locations for members with brain injury. Describe plans and process to ensure that initial and subsequent level-‐of-‐care determination for individuals with brain injury utilize nationally recognized, standardized and validated brain injury assessment tools that are sensitive to issues of cognitive disability, challenges to self-‐reporting, and ability to accommodate family and caregiver input. Ensure that assessment and re-‐assessment for level of care determinations are preformed in a conflict free manner. Ensure that Home and Vehicle modification service annual and lifetime limitations, within the Medicaid Waiver programs, are aligned and annually modified in a manner indexed to the Consumer Price Index for Urban Areas (CPIU). 9. Honor current exception to policy (ETP) rates for services for members with brain injury served in the Iowa Medicaid Home and Community Based Waiver for Brain Injury. 10. Require, in order to allow members to make informed decisions between MCO’s, transparency with regards to covered services, devices and prescription drugs; methodologies by which coverage is determined (e.g. how preferred drug list (PDL) decisions will be determined). Such information must be provided to members prior to the enrollment date. 11. Must provide for enrollees with disabilities related to brain injury. Specifically the plans should make special and additional efforts to outreach to enrollees with cognitive impairments or psychosocial disabilities to ensure that these enrollees make and attend appointments according to their plan of treatment. 12. Must define the criteria for access to services and levels of care for Medicaid members with identification of an independent party authorized to be available to members to rule upon disputes and enforce such rulings on behalf of members. Brain Injury Alliance of Iowa Requirements for Medicaid Managed Care Contracts for Companies Serving Individuals with Brain Injury in Iowa 2