Final
HIFA Hearing
HIFA WAIVER COMMITTEE
Votes:
Action Taken:
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At the outset, the committee was provided with the following handouts:
Memorandum from the Colorado Community Health Network
Memorandum from the Colorado Cross-Disability Coalition
Review of the Colorado HIFA Proposal by Schulte Consulting for
Colorado Legislative Council
Copy of power point presentation by CDHCPF
Questions submitted to and answers provided by the CDHCPF
from the committee meeting on August 9, 2005
Attachment I — HIFA Waiver fiscal analysis (purple paper)
Color Chart — Comparison of Current System and Proposed System (CDHCPF)
Memorandum on Colorado Family Care Concept from Theresa Sachs,
Health Management Associates, to Barbara Ladon
Statement about the Proposed Colorado Family Care Program by the Colorado
Children's Immunization Coalition
10:00 AM
Representative Boyd called the committee to order, discussed the agenda for the day, and noted that August 31, 2005, will be the last committee meeting at which time it will vote on the HIFA waiver.
10:10 AM
Mr. Steve Toole was introduced as the new executive director of the Department of Health Care Policy and Financing and he provided the committee with introductory remarks. He stressed the need to emphasize wellness and cost consciousness in the Medicaid program. He stated that the HIFA waiver is a good instrument for providing care to Colorado's families and underscored that he and the department will implement the waiver successfully, purchase care wisely, and keep the General Assembly informed as it goes through the process. He stated that the department does not intend to pursue other alternatives to implementing the waiver without the participation and approval of the General Assembly. Mr. Toole distributed Attachment A — an article in
Governing
magazine.
10:21 AM
Barbara Ladon, Department of Health Care Policy and Financing, began her presentation on the HIFA waiver — Colorado Family Care. This presentation has been made at each meeting. She stated the reasons why the department is choosing to implement proposed changes through a waiver vs. state plan amendments. A waiver is needed due to the design of Colorado Family Care. Waivers are required to provide enhanced services, and the current waiver for pregnant women in the Children's Basic Health Plan (CHP+) expires in 2006. There is an inherent merit in looking at the program in its totality rather than taking a piecemeal approach through state plan amendments.
Ms. Ladon emphasized that enrollment can grow under the program and no capping of enrollment will occur. Ms. Ladon noted that the children in both programs are very similar. However, CHP+ costs less and is run like those in the commercial market. Under CHP+ , children are seen more frequently in a doctor's office, whereas Medicaid too often treats children in the emergency room. Additionally, Medicaid is constrained by a lack of providers willing to serve its clients.
Ms. Ladon provided a discussion of the CORE and CORE PLUS benefit packages. She stated that most benefits are covered under CORE, and that a limited number of children will require CORE PLUS. The department will use the Medicaid definition of medical necessity for the waiver because it is the broadest definition.
10:47 AM
Ms. Ladon completed her presentation and took questions from the committee members. Questions centered around financing program expansions, the use of new tobacco tax revenue, "winners" and "losers" should the waiver be implemented, expansion of primary care physicians in the program, developmentally disabled children regarding the waiver, the 8.4% cap on expenditure growth, and employer-sponsored health care and its relation to the waiver. Ms. Ladon assured the members that "there will be no decrease in benefits to any clients" under the HIFA waiver.
11:13 AM
Eileen Ellis, Health Management Associates, began her presentation on Colorado Family Care and referred the committee to Attachments B and I and Attachment G in the HIFA Waiver Notebook submitted July 5, 2005. Ms. Ellis emphasized that the new tobacco tax money will finance program expansions, not savings. She stated that submitting a complete package to the federal government through the HIFA waiver will make it subject to a single evaluation process; multiple state plan amendments and single waivers would be too fragmented and subject to different evaluators without the full context.
Her role in the waiver process was to evaluate the work of state staff (Attachment G of HIFA Waiver Notebook); she referred the committee to Attachment I. She stated that budget neutrality under the waiver will result from multiple actions, one of which involves removal of the asset test which sends CHP+ children to Medicaid and frees up CHP+ dollars to cover children up to 200% FPL. There is no limit on the number of enrollees under the waiver but there will be an inflationary limit of 8.4% annually on the per capita cost. She does not anticipate rates will increase that much annually. She discussed enrollment projections for the first year of the waiver and worked off of charts included in Attachment I. Ms. Ellis stated that savings will come from a higher number of children being enrolled in managed care and children being served in primary/preventive care settings rather than an emergency room..
Ms. Ladon noted that the department used several actuarial contracts to do both enrollment and cost estimates. The analysis was done using FY 2002-03 actual data and is now being modified to include more recent actual data.
11:46 AM
Ms. Ellis completed her formal presentation and took questions from the committee. Questions centered around ongoing evaluation of the waiver program, the need to contract with good managed care organizations to ensure continuity of care within the rate structure, incentives for physicians, risk bands, rates, waiver withdrawal, contracts, and an exit strategy if the waiver does not work.
Ms. Ladon said that waivers are given up and modified. In those instances when a state cannot move forward under a waiver, it defaults to its existing Medicaid program. Ms. Ladon noted that should CMS requires certain amendments to the waiver, the state can withdraw the waiver request without incurring federal sanctions if it does not agree with the federally-proposed amendments. Additionally, a waiver can be withdrawn post approval into its second or third year. Similarly, contracts with HMOs can be cancelled at any time for cause and for no cause. The department will be proposing that any contract provider be licensed by the Department of Regulatory Agencies. CHP+ currently contracts with five providers to provide care statewide and is the largest pediatric network in the state.
12:17 PM
Georgia Macchietto, Pueblo County Department of Social Services, began her presentation. Ms. Macchietto stated that the counties have been struggling with CBMS since its implementation and that Medicaid is not working as it should as a result of this. She expressed concern that increased caseloads will put a burden on underfunded county staffs. Eligibility determinations and re-determinations will increase and many directors in the southern part of the state are concerned that this proposal may not be doable with current county staff and CBMS.
If clients cannot get into the system due to CBMS, then it doesn't matter if services are being expanded.
12:29 PM
Rep. Boyd announced the beginning of public testimony.
12:30 PM
Dr. Bruce MacHaffie, M.D., Colorado Chapter of the American Academy of Pediatrics, began testimony by stating that 50% of Medicaid clients use only 25% of the Medicaid budget, and these clients are children. His testimony centered on protecting services for Medicaid children, keeping the "T" in the EPSDT program, the need for an adequate number of staff in the provider network, and guaranteed eligibility to ensure continuity of care. Additionally, the state must get reimbursement rates up to the Medicare rate in order to get doctors to take Medicaid children as patients. Provider participation in Medicaid is a problem due to rates. Dr. MacHaffie spoke of the inequities in vaccinations — CHP+ children are not eligible for vaccines but Medicaid children are. This must be rectified in the waiver.
12:40 PM
Dr. Steve Poole, M.D., Children's Hospital, began testimony on the Colorado Children's Access Program. This pilot program was recently implemented with philanthropic funds and will work much like the HIFA waiver. Its mission is to attract private practitioners to accept Medicaid/CHIP+ children. Pediatricians want to see access to mental health and social services; this concern eclipses their concern over reimbursement rates. He identified barriers to implementing the Colorado Children's Access Program, but once addressed, pediatricians are agreeing to include Medicaid children as a percentage of their ongoing medical practices.
12:48 PM
Dr. William Wood, M.D., AmeriGroup, began his testimony. AmeriGroup serves as a Medicaid HMO in eight states. He stated the need to use a combined approach of physical health, mental health, and social supports. In doing so, costs are actually contained. AmeriGroup has seen no attempt by states uses their services to take an exit strategy from managed care for the Medicaid population.
12:57 PM
Lorez Meinhold, Colorado Consumer Health Initiative, presented a report from Cindy Mann, Center for Children and Families, Georgetown University, which evaluates the proposed Colorado HIFA waiver (Attachment C). Ms. Meinhold's testimony focused on the risks to implementing the waiver. Although she recommends not taking a piecemeal approach to proposed changes in the Medicaid program, she noted that sometimes a state cannot get out of a waiver.
01:09 PM
Committee recessed.
02:03 PM
Committee reconvened.
02:04 PM
Mary Shaw, Centura Health and St. Mary Corwin Medical Health, began her testimony. She identified who St. Mary Corwin serves and what the hospital means to the community. She stated that Pueblo's uninsured rate is estimated at 28%. She thinks that the HIFA waiver lacks good fiscal analysis. Ms. Shaw stated that St. Mary Corwin gets $0.19 Medicaid reimbursement on each dollar it spends. There are concerns that cost shifting will occur once implemented that will negatively affect the hospital's operations.
02:13 PM
Dr. Alethia Morgan, M.D., Colorado Medical Society, began her presentation. Dr. Morgan provided a position paper (Attachment D) in support of the HIFA waiver. She stated that the Colorado Medical Society will work to ensure that this waiver is successfully implemented. Dr. Morgan noted the following: a robust network of providers is necessary to implement the waiver; FQHCs must provide services efficiently; MCOs should be accredited to ensure access to appropriate care; and MCO administrative costs and profits must be capped to ensure that MCOs do not resort to cutting services to patients.
02:23 PM
Jonni Hulse began her presentation. Ms. Hulse expressed concern that special needs children might fall through the gaps and not receive the care they require. She is especially concerned about seizure disorders and the fact that the drug formulary under the waiver may exclude effective drugs which are currently available.
02:26 PM
Brenda LaCombe, Interim Director, Pueblo Coalition for the Medically Underserved, began her testimony. She commended the CDHCPF for its goals, but has concerns about the lack of details in the CORE and CORE PLUS benefit packages and CBMS.
02:34 PM
Dr. Michael Hurtado, Pueblo Community Health Center, began his testimony by requesting that the rate currently provided to community health centers be protected. Dr. Hurtado encouraged the committee to ensure that flexibility be built into the system for children who are most needy.
02:40 PM
Byron Gear, Pueblo Community Health Center began his testimony by expressing concern about rates. He asked for assurance that community health centers will not have to use their federal funds targeted to serve the uninsured for Medicaid clients. He noted that the Pueblo Community Health Center sees a high number of patients with diabetes when compared to other areas of the state. He expressed concern about the potential for only one or two MCOs that might serve Pueblo County. If so, the MCO must be required to contract with the Pueblo Community Health Center and to pay the center's reasonable costs.
02:43 PM
Lynne Procell, Health Care Program for Children with Special Needs, began her testimony. For the program she represents, 80% of the 400 children served are on Medicaid with a significant number of them on SSI. She stated that children on SSI will likely get the CORE PLUS package but what wonders about services for the others. She noted that physicians are concerned that MCOs will not allow them to practice medicine the way that they want to under the waiver.
02:50 PM
Jesse Thomas, UnitedHealth Group, began his testimony in support of the waiver and provided the committee with a handout (Attachment E). He noted that 55.0 million individuals are served nationwide by UnitedHealth Group, with 0.6 million Coloradans receiving their health care through UnitedHealth. He testified that his company wants to expand its operations in the state and to be part of the HIFA waiver program.
03:05 PM
Michele Longo, President of AAA Medical, began her testimony and provided a handout (Attachment F). Ms. Longo, who represents medical equipment providers, expressed concern over the 8.4% cap on reimbursement and the ability of clients in the HIFA waiver to access their medical equipment needs (durable medical goods) under the HIFA waiver.
03:13 PM
Marguerite Salazar, CFO, Valley-Wide Health Systems, began her testimony and stated that she is working with the CDHCPF on the matter of rates for the community health centers. Ms. Salazar stated that she was hopeful that reimbursement rates will be resolved prior to the August 31st committee meeting.
03:16 PM
Eileen Dennis, Parkview School-Based Wellness Center, began her testimony and distributed Attachment G. Ms. Dennis described the activities of Pueblo school-based wellness centers and the services they provide.
03:25 PM
Mike Kingsbury, SEIU Nurse Alliance, began his testimony. Mr. Kingsbury has attended all but the Durango meeting of the Joint Committee on Health and Human Services regarding the HIFA waiver. He stated that his organization has taken a formal position to oppose the waiver.
03:30 PM
Arnold Salazar, Colorado Behavioral Healthcare Council, testified in support of the waiver and the "carve-out" for behavioral health care. He distributed Attachments H and HH.
03:33 PM
Patrick Gordon, Rocky Mountain Health Plans, began his testimony which focused on the need for provider participation. He stated that there is nothing magic about managed care, it is only as good as the provider network it can bring to the table. He urges the committee to look at the contracting/competitive bid process — don't allow a MCO to promise to develop a provider network, the network must exist before the contract is signed. The waiver will be a long-term investment, savings will occur over decades not over budget cycles.
03:37 PM
Elizabeth Arenales, Colorado Center on Law and Policy, began her testimony and distributed Attachment Z. She discussed both the good and problematic aspects of the HIFA waiver, and concentrated on those aspects of the waiver which can be implemented without a HIFA waiver.
03:48 PM
Larry Velasco, Colorado Bluesky Enterprises, began his testimony. Mr Velasco talked about providing services to persons with developmental disabilities and expressed concerns about having to do more with less resources.
03:49 PM
Christy Blakely, Family Voices Colorado, began her testimony and distributed Attachment J. Ms. Blakely advocated the need to protect services for children with special needs and expressed concern over the CORE and CORE PLUS benefit packages. The questions posed in Attachment J will be forwarded to the DHCPF for answers.
03:55 PM
Kelly Stahlman, Family Voices Colorado, read into the record the testimony of Rhonda Stute (Attachment K). Ms. Stute came to testify before the committee in Greeley but was unable to testify because of illness.
04:02 PM
Dayna Higgs, Community Connections for Families, began her testimony. The organization she represents serves children with developmental disabilities. Her job is to identify the supports these children need according to a funding hierarchy. She expressed concerns with the waiver because the children her organization serves will receive benefits from the CORE package only, thus disrupting/ending services for these children.
04:06 PM
Patty Erjavic, El Pueblo Adolescent Treatment Center, began her testimony which centered around changes is federal funding for residential treatment centers (RTCs). Colorado may lose up to $36.0 million in federal funds in the next federal fiscal year because CMS is requiring that RTCs be certified accredited psychiatric hospitals.
04:12 PM
CW Smith, Parkview Medical Center, began his testimony. Mr. Smith expressed concerns around funding. How can enrollment be expanded and savings achieved? He noted that Pueblo and all of southern Colorado has a high Medicaid population. Funding is a major issue since 15% of the people seen at Parkview are Medicaid clients. Payment mechanisms are not timely. How would the payment modality work in the HIFA waiver? Will there be an adequate number of providers to serve the Medicaid clients in southern Colorado through managed care?
04:16 PM
Public testimony was closed. Rep. Boyd noted that Sharon Campbell, Colorado Coalition on Medicaid/CHP+ and Cochlear Implants, had signed up to testify but was unable to stay for the afternoon. Attachment L, summarizing her testimony and providing information on cochlear implants, was distributed.
04:17 PM
Mr. Toole was requested to provide some closing comments. Mr. Toole requests ten minutes at the August 31st meeting to explain how savings will be expanded while saving money. He reiterated that although concerns are expressed at these meetings about the waiver's impact on children with special needs and/or developmental disabilities, these children are not going to be included in the waiver. The waiver will not include the elderly, children with developmental disabilities, and foster care children. The department will also report to the committee on August 31st regarding rate negotiations with FQHCs.
04:24 PM
The committee adjourned.
04:27 PM
The committee reconvened to briefly discuss when it must vote; it was determined that it will meet the time frame set in SB 05-221 by meeting on August 31st.
04:30 PM
The committee adjourned.