The Title V Maternal and Child & Adolescent Health (MCAH) program and the Iowa Medicaid program have a close, mutually beneficial working relationship for approximately three decades.  The foundation for this relationship is the contract established each year between the Iowa Department of Public Health (IDPH) and the Iowa Department of Human Services (DHS) - Iowa Medicaid Enterprise (IME).  Typically, this agreement is established for a period of six years and renewed annually through an amendment that addresses language and budget updates.  This contract - known as the Omnibus Agreement - does not include services for children with special health care needs.

The Omnibus Agreement includes a Cooperative Agreement at its core with four attachments addressing specific program elements.  The purpose of each component is as follows:

• The Cooperative Agreement is established for the purpose of mutual cooperation, developing and sustaining a collaborative relationship to promote the availability of comprehensive, cost effective, and quality health services for its beneficiaries.  The development of a strong working relationship at the state level helps to prevent duplication of services and assists local human services offices and health agencies to develop cooperative relationships.  This core component addresses cooperation between Title V, Title X, WIC, Title XIX, and Title XXI programs. Roles of DHS and IDPH are identified, and program descriptions are included.  There is no funding attached to the Cooperative Agreement section.
• Attachment A - Informing and Care Engagement Administrative Services:  The purpose of Attachment A is to establish parameters for Title V local contract agencies to provide and receive payment for the following:
  • Informing families of new Medicaid eligible children ages 0 to 21 years of the benefits and services within the EPSDT program. 
  • Providing medical care coordination services for pregnant women and children on Medicaid who are not enrolled in a Medicaid Managed Care Organization (MCO).  This allows clients to be linked to a medical home and other needed services. The Medicaid MCOs hold the contractual responsibility for providing medical care coordination for MCO enrolled clients. 
  • Providing dental care coordination for any Medicaid enrolled pregnant woman or child.  This allows clients to be linked to oral health services provided by a dentist and coordinate oral health care services.
  • Providing presumptive eligibility determinations for low income pregnant women without health care coverage.  This service is open to the uninsured – both citizens and non-citizens.  It allows immediate Medicaid coverage for a limited period of time until a full eligibility determination can be made by Iowa DHS.  The pregnant woman is able to receive Medicaid covered maternal health services right away and establish an OB provider.
  • Providing interpretation services, as needed, for the above informing, care coordination, and presumptive eligibility services.  This service was newly implemented in FFY 2019.

Funding for the above services is paid by Iowa DHS to IDPH.  IDPH in turn provides fee-for-service payments to local Title V contract agencies that provide the services for clients in their service area.  Because the above are considered Medicaid administrative services, funding is derived from a 50 -50 split of Iowa DHS and Medicaid matching funds.  Medicaid data files provided by Iowa DHS, quality review of claims by IDPH, and performance measure reporting to DHS are built into this portion of the agreement. 

• Attachment B - EPSDT, Maternal Health, Oral Health, and 1st Five:  This attachment defines staffing for program support for the following:
  • EPSDT:  Provides IDPH staff support for quality monitoring of EPSDT services provided by Title V contract agencies.  Iowa Medicaid established a provider type known as Screening Centers for Title V so that local Title V Child & Adolescent (CAH) Health contract agencies can bill Medicaid (or Medicaid MCOs) for EPSDT screening services.  Bureau of Family Health staff provide training, consultation, technical assistance, and quality review of local contract agencies (e.g. chart audits).  Typically, the full well child exam is provided by primary care practitioners (the child’s medical home).  Title V agencies provide limited gap-filling direct care services. 
  • Maternal Health:  Provides IDPH staff support for quality monitoring of maternal health services provided by Title V contract agencies.  Iowa Medicaid established a provider type known as Maternal Health Centers for Title V so that local Title V Maternal Health contract agencies can bill Medicaid (or Medicaid MCOs) for prenatal and postpartum support services.  Bureau of Family Health staff provide training, consultation, technical assistance, and quality review of local contract agencies (e.g. chart audits).  Prenatal exams are provided by primary care practitioners (OB or other practitioners) in the maternal medical home.  Title V agencies provide limited gap-filling direct care services. 
  • Oral Health:  Provides IDPH staff support for implementation of the I-Smile™ dental home initiative to improve access to Medicaid dental prevention and treatment services for children and pregnant women.  It also provides for quality monitoring of oral health services provided by Title V contract agencies.  Oral health preventive services are billable by local Title V contract agencies to Iowa Medicaid for pregnant women and children under the Maternal Health Center and Screening Center provider types.  Oral Health Center staff provide training, consultation, technical assistance, and quality review of local contract agencies.  Facilitating access to dentists for dental exams is a primary focus.
  • 1st Five Children’s Healthy Mental Development:  Provides IDPH staff support for quality monitoring of 1st Five sites located within Title V contract agencies in 88 of Iowa’s 99 counties.  Education, consultation, and technical assistance is provided to 1st Five contract agencies to work with local primary care practices to ensure that recommended guidelines for developmental screening, referral processes, and identification of local resources are implemented for Medicaid enrolled children.  Funding for 1st Five program evaluation is also included.

Funding to support the above is a blend of IDPH, Iowa DHS, and Medicaid matching funds.  Data tracking by IDPH and performance measure reporting to DHS are built into this portion of the agreement.  The agreement also includes maintenance and support for TAVConnect, the integrated data system for documenting services.

• Attachment C – Maternal and Child Health and Hawki Outreach Services:  This attachment provides support for the following:
  • Maternal and Child Health Outreach Services:  Supports implementation of the toll-free 1-800 phone line so that women, youth, and families can receive information and referral for questions relating to prenatal care and well child services in addition to other services the family may need.  IDPH contracts with Iowa State University (ISU) Extension for staffing Iowa’s Healthy Families Line and Teen Line for youth.   Callers are able to be patched directly into their local Title V contract agency as needed so that local staff can provide assistance.  ISU Extension also stores and distributes numerous educational materials used by local Title V contract agencies.  Extensive data is reported each month on calls and support activities of the ISU Extension staff.
  • Hawki Outreach:  Provides support for a state level Hawki Outreach Coordinator and funding for local Title V CAH contract agencies to conduct Medicaid and Hawki outreach activities to promote enrollment.  Hawki is Iowa’s SCHIP program.  Local outreach activities are conducted with schools, faith-based organizations, medical and dental providers, special populations, and others. 

This component also supports the provision of presumptive eligibility services for children without health care coverage.  This service is open to uninsured children who are U.S. citizens.  It allows immediate Medicaid coverage for a limited period of time until a full eligibility determination can be made by Iowa DHS.  The child is able to receive covered health services right away and establish medical and dental homes.

Maternal and Child Health Outreach is supported by a blend of IDPH and Medicaid matching funds.  Hawki Outreach Services are supported by Iowa DHS and Medicaid matching funds.  Data is tracked by IDPH, DHS, and/or its contractors.  Performance measure reporting to DHS is also built into this portion of the agreement. 

• Attachment D – Medicaid and Vital Records Linked Data:  Provides support for linking vital records data files and Medicaid paid claims data to evaluate health outcomes to related to Medicaid services provided for pregnant women and children.  It provides important information on maternal characteristics and birth outcomes used for policy development and program planning.  Funding is a blend of IDPH and Medicaid matching funds.  Performance measure reporting to DHS is built into this portion of the agreement. 

Program outreach and enrollment

Promoting outreach and enrollment occurs at a number of levels.  Title V supports program various websites and the 1-800 Healthy Families Line and Teen Line, and contracts with local community-based public or private non-profit organizations serving all counties in Iowa.  Local contractors conduct outreach for Title V, Medicaid, and Hawki by linking with other programs (e.g. WIC), collaborating with local partners, participating in community events such as health fairs or Give Kids A Smile Day, publishing health promotion articles, posters, and brochures, and working with individual families.  Presumptive eligibility services for pregnant women and children are provided by Title V MCAH agencies and promote enrollment into Medicaid and Hawki.

Health care financing

Beyond Title V grant funding, Medicaid is the primary payer of client based services provided by local Title V MCAH contract agencies.  Gap-filling medical direct care services provided by Title V MCAH agencies are billed to Iowa Medicaid for Medicaid fee-for-service clients (approximately 5% of the Medicaid population).  Medical direct care services are billed to Iowa’s Medicaid MCOs for MCO enrolled clients (approximately 95% of the Medicaid population).  In March 2019, it was announced that UnitedHealthcare will be leaving Iowa as an MCO sometime in 2019 due to the inability to reach agreement on contract negotiations. UnitedHealthcare is therefore no longer enrolling Medicaid clients into their plan.  Centene’s Iowa Total Care was awarded a contract as a Medicaid MCO and will begin processing claims for services provided July 1, 2019 and forward.  Therefore, as of July 1, 2019, the MCOs serving Iowa Medicaid enrollees are Amerigroup and Iowa Total Care. 

Medical care coordination is included in the MCO’s contract with DHS.  As a result, local Title V MCAH contract agencies are not able to bill for medical care coordination services provided for MCO enrolled clients.  This has had a significant impact on the continuity of care that Title V contract agencies are able to provide for their population.  Agencies are able to bill IME for medical care coordination provided for the Medicaid fee-for-service population (approximately 5%) and for dental care coordination for any Medicaid enrolled MCAH client. 

Transportation services provided by local Title V MCAH agencies have also been significantly impacted by the advent of Medicaid MCOs.  Historically, Title V agencies have been able to arrange and bill specific types of transportation services for Medicaid clients through their Screening Center or Maternal Health Center provider types.  This enabled local staff to assist clients to gain access to Medicaid covered services/appointments.  This ability is now limited to only the Medicaid fee-for-service population, as each Medicaid MCO has a transportation broker for handling rides for the MCO enrolled population.  Iowa Medicaid also has a transportation broker for serving the Medicaid fee-for-service population.  MCAH agencies have experienced many reports from clients regarding difficulties and lack of flexibility of services offered through the transportation brokers.

Waiver Programs

Iowa currently has seven Home and Community Based Services (HCBS) Waivers that provide funding and individualized supports to allow eligible members to live in their own homes and communities. Five of these Waivers apply specifically to Iowa CYSHCN: the Health and Disability Waiver, the Intellectual Disability Waiver, the Brain Injury Waiver, the Physical Disability Waiver, and the Children’s Mental Health Waiver. Waivers for CYSHCN currently cover about 16,500 children. Nearly 6,000 children are on waitlists for waiver programs.

DCCH provides consultation and technical assistance activities related to agencies and participants under the age of 21 with complex health care needs, and who are recipients of EPSDT or the HCBS Health and Disability Waiver program. DCCH also provides consultation, technical assistance, planning and care coordination activities for about 600 individuals who are on the Health and Disability Waiver waiting list and not yet eligible for Medicaid.

Joint Policy Level Decision Making

Over the years, the Bureau Chief of Family Health has experienced many opportunities to meet with Iowa’s Medicaid Director on joint policy issues and problem resolution.  Examples include working together to plan, pilot, and fully implement the informing and care coordination program; shifting Iowa’s care management from ‘targeted case management’ to ‘administrative care coordination’ based upon federal clarification; including interpretation for PE, informing, and care coordination as a service paid by IDPH to local MCAH agencies through DHS funding;  increasing Medicaid’s reimbursement rate for certain services based upon Cost Analyses completed by local Title V MCAH contract agencies;  establishing third party billing policies; and resolving some instances of lack of payment to local contract agencies from the MCOs. 

Approximately thirteen staff from various programs within the Bureau of Family Health and Oral Health Center meet monthly with the IME Maternal Health Center & Screening Center Project Manager, IME Oral Health Project Manager, and IME Contract Manager. The meetings provide an opportunity for staff to pose questions and concerns, provide input, and receive guidance and updates from IME on Medicaid policy and current issues.  Challenges that local MCAH agency contractors have experienced with the April 1, 2016 transition to Medicaid Managed Care are presented and discussed.  IDPH staff share information on progress within Title V MCAH and other programs of mutual interest.