Final
HIFA Waiver Hearing

HIFA WAIVER COMMITTEE

Votes:
Action Taken:
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Prior to the meeting, a number of documents were distributed to committee members included the Department of Health Care Policy and Financing's response to questions raised at the July 27 meeting in Greeley (Attachment A), the Department's response to questions raised by Sarah Schulte, consultant to Legislative Council (Attachment B), and the Department's response to questions raised by Representative Boyd (Attachment C).


09:09 AM - Presentation by the Department of Health Care Policy and Financing

Bill Heller, Colorado Department of Health Care Policy and Financing, began his presentation regarding Health Insurance Flexibility and Accountability (HIFA) waivers and explained that HIFA Medicaid waivers allow states to use innovative approaches to expand Medicaid eligibility. He discussed required elements of a HIFA waiver. The HIFA waiver proposed by the Department of Health Care Policy and Financing, called the Colorado Family Cares Program, will combine children and certain adults who are eligible for Medicaid, and children and pregnant women who are eligible for the Children's Basic Health Plan (CHP+), into one program. The program will expand the Medicaid eligibility for certain adults from 60 percent to 100 percent of the Federal Poverty Level (FPL). Mr. Heller discussed research findings regarding participants in CHP+ and Medicaid and childhood illnesses and injuries treated in CHP+ and Medicaid. According to Mr. Heller, advantages of the Colorado Family Cares Program include a streamlining of the CHP+ and Medicaid programs and increased provider reimbursement rates. Additionally, under the program, benefits for CHP+ eligible children will be expanded. Mr. Heller described the benefits that are available to children and adults under the program. The Colorado Family Cares program will offer a CORE benefit package that includes routine physical examinations and screenings, and immunizations. The CORE Plus Benefits package includes expanded mental health services, extended physical and speech therapies, additional durable medical equipment, and additional oral health services. He discussed the financial analysis of the program. He stated that the program requires no additional general funds and that the program is not a block grant for Medicaid.

09:29 AM

Mr. Heller responded to questions from the committee regarding budget neutrality requirements and what would happens if the contracted organization leaves the market. Mr. Heller stated that the state will have a state-funded managed care network in placed to serve as a safety net. He stated that part of the contracting process will involve checking the financial stability of the company. As far as budget neutrality, Mr. Heller stated that the department must meet both state and federal budget neutrality requirements. Representative Cloer asked what changes Colorado Family Care would make to the Early Periodic Screening Diagnosis and Treatment (EPSDT) program and Mr. Heller stated that the program provides the full EPSDT benefit. He stated that all children will have access to CORE Benefits, and if necessary, CORE Plus benefits. Representative Cloer asked why it was necessary to implement the program through a HIFA waiver. Mr. Heller responded that components of the program could be accomplished through a state plan amendment, but that it would be more efficient to do all of the program expansions under one waiver. Mr. Heller responded to a question regarding what effect the program would have on community health clinics. He stated that the program is planning to use the community health clinics as they are currently used. He stated that CHP+ currently depends heavily on the community health clinics. Senator Hagedorn asked whether the department has negotiated with community health clinics regarding the waiver program.

09:38 AM

Representative Frangas asked how the program would reduce emergency room visits. Mr. Heller responded that increasing the reimbursement rate will increase the number of providers who are participating in the program and therefore individuals will have better to access to primary care which will prevent emergency room visits. He stated that streamlining Medicaid and CHP+ into two programs will decrease administrative costs for providers. Mr. Heller responded to questions from Representative Soper regarding the employer-sponsored insurance pilot program. Mr. Heller responded to questions from Senator Hanna regarding budget neutrality requirements and limits on dental care and durable medical equipment for children. Mr. Heller stated that the program will cover dental caps for children, and that most dental care is covered within the $500 limit on dental care specified in the program. Further, he stated that the durable medical benefit limit covers 94.83 percent of the individuals who need durable medical benefits. Senator Shaffer raised a number of points regarding the development of the program and Mr. Heller responded that the Department reviewed actual data of Medicaid and CHP+ members in order to formulate the program. He further stated that the Department is currently working with an actuary to review the financial data of the program. Senator Sandoval raised a number of questions regarding the employer-sponsored insurance pilot program. Representative Berens requested a specific financial analysis of the program. Mr. Heller responded to questions from Representative Frangas regarding the increase in provider reimbursement rates and discussed reimbursement rates to federally qualified health centers. Mr. Heller responded to questions from the committee regarding whether patients who are enrolled in managed care organizations will be subject to a commercial drug formulary. Senator Hanna asked how the Department would prevent fraud and abuse within the new program. Mr. Heller responded that the Department calculated the costs of the program to account for the inefficiencies associated with fraud and abuse. Mr. Heller responded to questions from the committee regarding how the competitive bidding process will be structured.

10:18 AM - Presentation by Sarah Schulte

Ms. Schulte began her presentation by discussing the key changes to Medicaid and CHP+ under the Colorado Family Cares Program and a handout of her presentation was provided to the committee (Attachment D). She stated that the program will cover parents up to 100 percent of FPL if there are adequate funds, but that no new children and pregnant women are covered under the program. Under Colorado Family Care, CHP+ kids will receive additional benefits, including expanded mental health benefits. Parents will receive preventative services, but will have limits on other benefits. Ms. Schulte stated that the increased enrollment and benefits expansion will be funded by a wholesale shift to managed care. Today 22 percent of Medicaid individuals are enrolled in managed care, and under the Colorado Family Cares program, 85 percent of Medicaid individuals will be enrolled in health maintenance organizations. She stated that today, safety net providers are available to Medicaid patients, however, under Colorado Family Cares, there is no requirement that managed care organizations contract with safety net providers. She responded to a number of questions from the committee regarding safety net provider reimbursement. Ms. Schulte discussed the budget neutrality aspect of the HIFA waiver. She stated that, without the waiver, there is not growth cap on federal funding for Medicaid and CHP+ programs. Under the waiver program, there is a growth cap on per capita federal funding over the waiver period based on normal anticipated growth.

10:38 AM

Ms. Schulte responded to questions from the committee regarding what aspects of the program require a HIFA waiver, stating that no aspect of the program requires a HIFA waiver. Ms. Schulte responded to questions from Senator Sandoval regarding the use of the tobacco tax moneys to fund program expansions in CHP+ and Medicaid. She raised a number of questions regarding the waiver including: what are the assumptions used to generate the estimated 2 to 17 percent savings in Medicaid children costs, how much money will be saved by enrolling adults and women in the program, and are parents between 60 and 100 percent of poverty funded with the tobacco tax or with program savings?

10:45 AM

The committee recessed.

11:06 AM

The committee reconvened.

11:09 AM - Presentation by the La Plata County Department of Social Services

Patricia Carlson, Director, La Plata County Department of Social Services, discussed problems with the implementation of the Colorado Benefits Management System (CBMS). She stated her concern with how children who are in foster care and adoption services will fit under the new program. She stated that it is unclear as to how children who are in foster care who are reunited with their families will transition between regular Medicaid and CHP+ and the Colorado Family Cares program. She raised a number of questions as to how the waiver program will affect county administrative costs and reimbursements for those costs. She responded to questions from the committee regarding CBMS, stating that CBMS is slowly improving.

11:16 AM

Representative Boyd announced that the next public meeting would be held in Pueblo on August 26 from 10 to 4. Senator Hagedorn opened the public testimony portion of the meeting.

11:17 AM - Michele Longo, AAA Medical, discussed the cap on the durable medical equipment for adults under the Colorado Family Cares Program. She questioned what happens to the people that exceed the annual limit on durable medical equipment. She stated that the inability of individuals to access durable medical equipment can cause more medical problems in the future. She distributed a copy of her testimony to the committee (Attachment E).

11:22 AM - Jill Brooks, parent, testified that she did not receive much information about the waiver program. Even though her daughter is carved out of the Colorado Family Cares program, she testified regarding her concerns that children with special needs will not be able to access appropriate services. She responded to questions from Representative Cloer.

11:24 AM - Dr. Marvin Collentine, Valley Wide Health Systems, testified regarding the importance of maintaining the community health center system in Colorado. He discussed the Valley Wide Community Health Clinics. He stated that the proposed reimbursement rate change must strengthen community health clinics, not weaken them. Dr. Collentine responded to questions from the committee regarding the perception of Valley Wide Health Clinics among the patients. He further responded to questions from the committee regarding the perceived threat of the waiver program to the community health clinics.

11:32 AM - Carolyn Redwine, Valley Wide Health Systems, described the clinics operated by the Valley Wide system in Durango and stated that the clinics receive no federal grant moneys. She stated that a reduction in reimbursement rates would make it impossible for the clinics to offer the same amount of care. She stated that lowering reimbursement rates would affect the ability of Medicaid and CHP+ patients to find care, as Valley Wide is the only clinic in Durango currently accepting Medicaid patients.

11:35 AM - Dr. Bern Heath, Southwest Colorado Mental Health Center, testified to the unique aspects of mental health delivery in rural areas. He stated that there are a lot of uncertainties as to the implementation of the program. He further stated that a change in the leadership at the Department of Health Care Policy and Financing raises uncertainties as to the implementation of the mental health program. He testified that although administrative programs may be streamlined, that doesn't necessarily streamline the delivery of health care services and that the current carve out of mental health services would preserve the seamless delivery of mental health services. He stated that mental health services have already been compromised by budget cuts. He responded to questions from the committee.

11:42 AM - Jackie Morlan, Community Connections, testified that Medicaid dollars may not be available in the future. She testified that individuals often exceed the current limit on durable medical equipment and expressed concern as to how persons will access CORE plus services. She spoke regarding her concern that mental health benefits will be reduced under the waiver program.

11:46 AM - Steve Erkenbrack, Rocky Mountain Health Plans, testified in support of the concept of the HIFA waiver. He spoke to his concerns regarding the specifics of the waiver including the 8 percent cap on costs. He discussed different methods of delivering Medicaid services, and explained the programs operated by Rocky Mountain Health Plans. He discussed rate-setting in Medicaid and CHP+ capitated models. He stated his concern with the speed at which the waiver program is being proposed and that actual state input into the program is necessary. He responded to questions from the committee.

11:58 AM - Johnny Bolson, citizen, testified regarding his concerns with the limit on durable medical benefits. He discussed the costs associated with not providing proper medical equipment and testified that it was difficult to find a Medicaid primary care provider until he started going to Valley Wide Health Care Centers.

12:00 PM - Therese Yanan, Native American P&A, testified regarding her concerns that the Department of Health Care Policy and Financing has not consulted with the Native American community regarding the waiver program.

12:02 PM - Ruth Aponte, American Academy of Pediatrics, distributed a handout to the Committee (Attachment F). She stated that the Academy supports the concepts of the HIFA waiver, especially the concept of providing a medical home for children. She stated that the provider rate proposed for the program will not be enough to encourage providers to participate in the Medicaid program. She testified that safety net providers are vital to the operation of the HIFA waiver, but that it is necessary to have private provider participation in the program. She spoke regarding the benefits of the program including seamlessness, and stated that it is important to have an adequate and open appeals process where families can receive assistance and answers. She testified that the department should implement a quality assurance process that measures health and patient satisfaction indicators. She stated that the HIFA waiver provides an opportunity to increase childhood immunizations in Colorado. She asked how questions regarding the HIFA waiver will be resolved. Senator Hagedorn spoke regarding Senate Bill 05-221 and the public testimony process.

12:17 PM - Shawn Collins-Grim, parent, testified that when her family lived in Missouri, her special needs child qualified for Medicaid, but that her daughter does not qualify for Medicaid in Colorado. She asked the committee to consider children who are in the Medicaid system who may be in the system for years. She stated that it is important that children have access to services that they need and that accessing adequate information is very difficult. She testified that her daughter's eligibility for Medicaid may be made solely on the family's income rather than her disability.

12:26 PM - Yvette Tanner, parent, testified regarding her family's experiences accessing services for her son. She asked at what age the CORE and CORE Plus will end, and stated that she has a number of questions regarding the program. She stated that it is very difficult to access services in a rural area and raised a number of questions regarding CORE and CORE Plus benefits. She responded to questions from the committee.

12:38 PM - Dr. Pakin Chauphuri, testified that there are a number of aspects of the program which she likes, including the streamlining of CHP+ and Medicaid. She testified that she accepts both Medicaid and CHP+ children, but that it is difficult to accept patients at the rates that Medicaid and CHP+ pays providers.

12:44 PM - Patsy Ford, Public Health Nurse, testified regarding her concerns about how individuals will qualify for and transition between CORE and CORE Plus services. She spoke to the importance of safety net providers.

12:46 PM - The public hearing was closed. The committee adjourned.