Medicaid Managed Care and Long-Term Supports and Services
Authored By: Iowa Legal Aid
Iowa's change to Medicaid Managed Care has brought many changes for Medicaid members. How is the change affecting people who receive long-term supports and services like nursing home care and Medicaid waiver services in their own homes?
How Long Can I keep my Case Manager/Why Do I Have a New Case Manager?
Managed Care started on April 1, 2016. People who have long-term supports and services (LTSS) have a case manager who helps coordinate their care. Many times, the case manager has worked with the Medicaid member for many years. Case managers might work for an agency or an Iowa county or region.
People who receive LTSS could keep their case managers for six months after Managed Care started, or until September 30, 2016. After September 30, the Managed Care Organizations (MCOs) can require those case managers to sign new contracts with the MCOs if they want to keep being Medicaid providers.
If the case managers don't want to sign a new contract with the MCO, then the Medicaid members may have to switch to case managers who work for the MCO. Currently, only one MCO (Amerihealth Caritas) is allowing people to keep case managers who don't work for the MCO. The other two MCOs (United Healthcare and Amerigroup) did not sign contracts with existing case managers. Instead, those two MCOs have hired their own case managers. Medicaid patients may have to form a relationship with a new case manager.
I am in a Nursing Home. How Will Managed Care Affect Me?
If you are in a nursing facility and Medicaid is paying for your stay there, you may or may not see a difference from the change to managed care. Your client participation rate should remain the same. Your may be assigned a different case manager, as mentioned above.
How are my Medicaid Waiver Services Going to Be Affected?
Medicaid Waiver programs help people remain in the community instead of moving into an institution. Iowa has eight Medicaid Waiver programs. Those programs are for people who have medical conditions or disabilities that make it difficult to stay in their own home without help. With services from the Medicaid Waiver program, people can stay in their own home or a group home instead of living in a nursing facility or an intermediate care facility.
About the same time as the switch to Managed Care, Iowa also made some changes to its Medicaid Waiver programs. Iowa is now using new assessment forms to determine whether a person qualifies to receive waiver services. The assessment is done each year. Iowa has contracted with Telligen, an Iowa-based company, to perform the assessments for most of the waiver programs. For the Children's Mental Health Waiver and the Habilitation Program, the person's case manager will do the assessment.
If someone is approved for waiver services, the MCO will then use the information in the assessment to develop a service plan. A service plan says what kinds of services you will receive under the waiver. That means that the answers and information provided to Telligen and your case manager are very important. The assessment needs to capture a true picture of the individual's daily life – areas of need as well as areas of independence. If you need help with showering/bathing, dressing, or using the bathroom, make the needs clear to the Telligen assessor or your case manager.
- Elderly Waiver
- Physical Disability Waiver
- Health and Disability Waiver
- AIDS/HIV Waiver
- Intellectual Disability Waiver
- Brain Injury Waiver
- Children's Mental Health Waiver (for children with chronic mental illness)
- Habilitation Services (for adults with chronic mental illness)
The MCO will approve or deny the waiver services plan. The MCO may decide that you don't need a particular service, or that you need a particular service, but that you don't need as much as you requested or feel you need. The MCO will send you a written copy of the service plan.
IMPORTANT: If you disagree with any part of the MCO's decision, you can file an appeal with the MCO. The MCO will then make a decision about whether its initial decision was correct. If you disagree with the MCO's decision, you can then request a State Fair Hearing. At a State Fair Hearing, an Iowa Administrative Law Judge (ALJ) will conduct a hearing. At the hearing, both you and the MCO's representative may testify and present evidence. After considering all the evidence, the ALJ will issue a written proposed decision. If either party disagrees with the proposed decision, they can request that the Director of Iowa Department of Human Services (DHS) review the decision.
Once you are approved for a waiver program, you may have a period of time before your service plan is approved. Ideally, this should be a month or less, but can sometimes take longer. If you believe that the waiting period is too long, you can file a grievance with your MCO.
IMPORTANT: If you want someone else to file a grievance or appeal for you, you must give him/her written permission to do that. This is something the MCOs require.
Where can I get help with an appeal?
Iowa Legal Aid provides help to low-income Iowans.
- To apply for help from Iowa Legal Aid:
- Iowans age 60 and over, call 800-992-8161 or
- Apply online here: Iowa Legal Aid Online Application