Medicaid

In this February 2016 file photo, Colin Edberg, 13, looks at photos with his father, Jeff Edberg of Iowa City, during lunch at KFC in Dubuque.

ADAM WESLEY, The Gazette

DES MOINES — A month ago, when Iowa’s Medicaid system was thrown for a loop with the exit of one of its managed-care companies, Department of Human Services Director Jerry Foxhoven admitted there have been “some bumps” during the transition period.

“When Director Foxhoven said there would be ‘bumps’ in the road, I took great issue with that. I wrote to him two weeks later to say, ‘My son is not a bump in your road,’” said Jeff Edberg of Iowa City, referring to his 15-year-old son Colin.

Colin, who has mental and physical disabilities, lives at Dubuque-based Hills and Dales, an intermediate-care facility for children and adults. He relied on AmeriHealth Caritas for his Medicaid coverage.

But recent changes in Iowa’s Medicaid system have affected families such as the Edbergs, who are among thousands of Iowans who no longer have a choice in their managed-care provider.

As of this past Friday, in addition to the state fee-for-service program, Iowa only has two insurers on its managed-care system — Amerigroup Iowa and UnitedHealthcare of the River Valley — to cover roughly 570,000 members, according to the latest DHS quarterly report. Not only was a large portion of the Medicaid population unable to make a choice in their managed-care organization, but an additional 10,000 people have been moved to a traditional fee-for-service program within the state due to lack of insurer capacity.

The Gazette followed the Edberg family through the first year of Iowa’s private managed-care rollout, launched in 2016. The paper checked back with the Edbergs at a time when they believe Colin’s services are in jeopardy.

“I am at a loss,” Jeff said. “I am sick about it. I’m afraid for my son and his future.”

Members moved

Recent confusion about the state’s managed-case system began in October when AmeriHealth — one of three managed-care organizations selected for the program — announced it was withdrawing from Iowa’s Medicaid program.

AmeriHealth, which covered the largest concentration of the state’s most in need — and therefore most expensive — population, exited the program Friday. Those members were moved to UnitedHealthcare, DHS officials announced early last month.

However, members were told they could opt to switch to Amerigroup before Nov. 16, the managed-care organization Jeff Edberg chose for Colin. This was the provider with which Hills and Dales, as well as the doctors’ group in Dubuque, Medical Associates, had signed.

Edberg received a card from Amerigroup last week confirming Colin was enrolled.

But the next day, a notice was sent out by DHS to state lawmakers stating Amerigroup did not “currently have capacity to take any new members, including those who have actively chosen Amerigroup Iowa as their (managed-care organization).”

DHS spokesman Matt Highland said 10,121 people chose Amerigroup following AmeriHealth’s withdrawal. As a result of Amerigroup’s statement, the department opted to provide coverage for those enrollees through the existing Iowa Medicaid Fee-for-Service program.

Providers signed on with AmeriHealth also will continue coverage of those switched to the fee-for-service program, he said.

“For providers to enroll with the (managed-care organizations), they must first enroll with the Iowa Medicaid Enterprise,” Highland said. “So AmeriHealth Caritas providers would already be enrolled with IME.”

Edberg said he’s heard from Hills and Dales and from the Dubuque doctors’ group Colin’s services still will be covered under the new program. However, he remains frustrated, saying he believes his son’s health is in the balance.

“This isn’t buying stationery, this isn’t where do I go to upgrade my iPhone,” Edberg said. “This is my son’s well-being and his very life.

“If he wandered outside of Hills and Dales, he would not live an hour. He would wander in front of traffic, he does not understand that sort of thing.”

On any given month, DHS’s Highland said, there are 40,000 members on the fee-for-service program, including those who are in their tentative assignment period before having coverage through a managed-care organization.

An additional 10,121 people would not be a significant challenge for the state to take on. However, in a memo sent to lawmakers last week, department officials noted they are reaching out to “current case management agencies to see if they are able to assist during the transition.”

“It’s important to know for members, there is no gap in coverage,” Highland said. “It’s just who is giving coverage that has changed.”

Iowa’s Medicaid population was covered under the state’s Medicaid fee-for-service model until the majority of the population was transitioned to managed care in April 2016.

Fee-for-service is a payment model in which services are paid separately to health care providers, whether it’s a procedure or a doctor’s office visit.

Rep. Liz Mathis, D-Hiawatha, said late last month the two programs also differs philosophically. Managed care would take a holistic look at a patient’s health for the long-term, rather just address a current need.

Highland said when the state learned AmeriHealth was withdrawing from Iowa’s Medicaid program, it reached out to Amerigroup and UnitedHealthcare to determine if the remaining two insurers could handle an influx of members.

At that time, Highland said the department learned Amerigroup did not have capacity to take on a high number of Medicaid enrollees from AmeriHealth. It was upon a follow-up — at an unspecified date — that DHS learned Amerigroup could not take on any new members.

An Amerigroup spokesman did not respond to requests for comment by deadline.

On Monday, the department posted on its website that officials are closely monitoring Amerigroup as it continues “ramping up their capacity.”

Highland said the state does not have a clear timeline when Amerigroup could take on more members.

The remaining managed-care organization, UnitedHealthcare, ramped up for the influx of new members Friday by expanding its provider network and hiring approximately 400 more case managers. (See sidebar on page B2.)

As the landscape of Iowa’s Medicaid evolves — and will continue to do so — Jeff Edberg said the issues with the system need to be solved for members like his teenage son Colin.

“Today he’s safe, but I’m still pretty terrified,” Edberg said.

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