Scope of Services: The Iowa Wellness Plan members will receive a comprehensive, commercial-like benefit package based on the State Employee Plan benefits, which will ensure coverage for all of the essential health benefits as required by the Affordable Care Act. Iowa will supplement the State Employee Plan services with supplemental dental benefits, similar to those provided in the Medicaid State Plan. Mental health and substance use disorder and dental benefits will be provided on as carved out benefits on a contracted basis.
Eligible Provider Population: Iowa’s ACO strategy under its Iowa Wellness Plan is centered on Patient Managers, providers that signed both a Wellness Provider Agreement and a Medicaid Provider Agreement, are part of an ACO, and agree to accept the terms of the agreement with the ACO to serve as a primary care/patient-centered medical home for the member.
Eligible Patient Population: The Iowa Wellness Plan is targeted for individuals who are between ages 19 through 64 who do not have access to Medicare or other comprehensive Medicaid coverage, and who are not eligible for cost-effective employer-sponsored coverage. Individuals, who do not have access to cost-effective employer-sponsored coverage, with income up to and including 100 percent of the federal poverty level (FPL) based on the modified adjusted gross income methodology, are considered eligible, and individuals with income up to 133 percent of the FPL who are medically frail will be considered eligible.
Attribution: Medicaid beneficiaries enrolled in the Iowa Wellness Plan choose a primary care provider (known as a Patient Manager); the beneficiary is assigned to the ACO if the primary care provider is participating. If a beneficiary does not choose a provider, he is assigned to the provider with whom he had the highest number of unique visits (using evaluation and management codes in the most recent 12 months of claims history).
The Iowa Health and Wellness Plan was authorized by Chapter 138 of the Acts of 2013. Iowa has submitted to CMS a request for an 1115 Demonstration Waiver to implement the Iowa Wellness Plan. It is also using funds from a State Innovation Model grant to plan for a multi-payer accountable care organization model.
Under a draft accountable care organization (ACO) agreement released by Iowa Medicaid, an ACO must possess the corporate resources and structure necessary to perform its responsibilities under the agreement and successfully implement and operate the ACO. ACOs must enter into written agreements or contracts with the patient managers (PMs).
ACOs must also established a governing body with responsibility for setting policy, developing and implementing a model of care, establishing best practices, setting and monitoring quality goals, and assessing PM performance and addressing deficiencies. The ACO must also demonstrate meaningful involvement of a Chief Medical Officer and PMs in the governance structure.
The agreement also stipulates that the ACO shall have a consumer advisory board that meets regularly and advises on ACO policies and programs including cultural competency, outreach plans, member education materials, prevention programs, member satisfaction surveys, and quality improvement programs.
|Criteria for Participation||
A draft accountable care organization (ACO) agreement released by Iowa Medicaid clarified that ACOs must be active Iowa Medicaid providers. They must also be able to demonstrate an integrated delivery system and share clinical information in a timely manner; and implement a model of care and financial management structure that promotes provider accountability, quality improvement, and improved health outcomes.
Among other responsibilities for ACOs that wish to participate in the Wellness Plan are that they must:
In the first year of the operation of an accountable care organization (ACO), primary care physicians in it will initially be paid on a fee-for-service basis, and they will receive a care coordination payment for managing referrals and coordinating care. The ACO will receive bonus payment according to the performance targets and methodology detailed in a Value Index Score Medical Home Bonus Document.
If the ACO qualifies, the Medicaid agency will pay the ACO three bonus payments:
In subsequent years, ACOs will be subject to a risk-adjusted global budget with shared savings (and, within five years of the initial contract year, two-way risk sharing) based on quality performance.
|Support for Infrastructure||
Under a draft accountable care organization (ACO) agreement released by Iowa Medicaid, the Department of Human Services will:
|Measurement and Evaluation||
Shared savings opportunities for ACOs participating in the Iowa Wellness Plan begin in their second year of operation and will eventually be contingent upon performance on quality metrics. These quality metrics will be implemented in a phased approach and may include attributed participant experience, primary and secondary prevention, tertiary prevention, population health status, continuity of care, chronic and follow-up care, and efficiency. Implementation of quality metrics is required within three years of the ACO contracting with the Iowa Wellness Plan.
In the first year of operation, one of the bonus payments for which ACOs are eligible will be a medical home bonus payment. The payment will be based on performance on metrics that fall under four categories: (1) person-focused care; (2) first contact with the health care system; (3) comprehensive, coordinated care and (4) transfer of information.