The Wisconsin Department of Health Services, on last week Thursday, submitted its revised Family Care/Include Respect I Self-Direct (IRIS) 2.0 concept paper to the legislature’s Joint Finance Committee.
The 2015-17 state budget directed DHS to make a number of changes to the Family Care and IRIS programs. DHS held public hearings throughout the state last fall and released a preliminary concept paper in early March, with further public hearings on March 7. About 350 people attended the hearings last month, and DHS received testimony from 202 people. As a result of that additional input, the 16-page concept paper released on March 1 was expanded to 19 pages. Click here to read the revised paper released Thursday.
The Joint Finance Committee must now review and approve the concept paper, which will then be used by DHS to write a waiver application to the federal government. The concept paper released Thursday contains some revised language over the draft paper released in early March. The new/additional language includes:
Executive Summary – Outlines of Features of the proposed new model:
Ongoing Consumer/Stakeholder Engagement:
DHS will continue to have discussions with MCOs, potential IHAs, advocates, counties and other stakeholders as the waiver is being developed. Upon implementation of Family Care/IRIS 2.0, the following steps will be taken to remain engaged with consumers and stakeholders.
- All IHAs will be required to have a consumer advisory council. IHAs will also be required to have a provider advisory council and to provide DHS with regular updates on the work of these groups. These councils will provide consumers and providers regular and ongoing mechanisms to voice concerns about the operations of the IHA and to make recommendations about areas in which improvements can be made.
- DHS will receive regular input from consumers, providers, and other stakeholders to advise DHS on procedures of Family Care/IRIS 2.0 and its oversight of IHAs and ADRCs.
- DHS will conduct quarterly listening sessions in each zone at least through the first year of the Family Care/IRIS 2.0 program. Representatives of IHAs and ADRCs in the zone will be required to attend in person.
- Program participants have the choice to live in the least restrictive and most integrated setting appropriate to their needs.
- Functional and financial eligibility will remain the same as it is today.
- When an IRIS member self-directs long-term care services the member, in consultation with the IRIS Consultant Agency (ICA), develops a plan to meet the member’s needs. The member determines who will provide the services specified in the care plan and manages and directs payments to service providers.
- Members who choose to self-direct their long-term care services will continue to have employer and budget authority and responsibility. Participants will continue to manage and direct their own individual service budget.
- The new concept paper also includes language about IHA responsibilities relating to IRIS.
- Readiness reviews will ensure that each IHA is prepared to serve Family Care/IRIS 2.0 members and has Culturally competent staff that meet the needs of people of diverse identities.
- DHS will provide oversight to ensure ongoing compliance with program requirements.
- Sufficient number, mix, and geographic distribution of providers of all services in the benefit package based on the location of providers and members and distance, travel time, and means of transportation ordinarily used by program participants.
Network providers offer hours of operation that are no less than the hours of operation offered to commercial members or comparable Medicaid fee-for-service members, if the provider serves only Medicaid members.
- Benefit package services that are necessary to support outcomes or that are medically necessary are available 24 hours a day, seven days a week.
- Members have access to prevention and wellness services.
Availability of specialized expertise.
Cultural competence in the development of member care plans and the availability of service providers.
Physical accessibility of services.
Family Care/IRIS 2.0 will include network adequacy standards for medical services. These standards will be guided by the existing requirements in Medicaid managed care programs that govern time and distance for specific services and require the documentation of the number and type of providers, whether providers are accepting new patients, and the geographic location of providers in relation to program members.
In addition, there will be no auto enrollment for Medicare services. Wisconsin does not have the authority to enroll Medicare members in Medicare Advantage and will not do so. Medicare members will not be required to enroll in managed care for non-long-term care services. Individuals who are dually eligible for Medicaid and Medicare have the right to choose to obtain their Medicare benefits through fee-for-service Medicare or through a managed Medicare program.
- Having three IHAs and three zones will mitigate the financial volatility of IHAs and ensure stability for the long-term care system. Based on the actuarial analysis, three zoness with three IHAs will maximize the financial stability of the IHAs. While financial results will vary, the actuarial model projects that in any given year, 85 percent of the time, profits are not expected to be greater than 2.5 percent and losses are not expected to be greater than 2.5 percent. If profits and losses are not within these margins, DHS will review the rate setting process to assess the variance.
- If an IHA fails to meet contract standards and performance requirements, the Department will have authority to assess fines and liquidated damages to ensure compliance
- DHS may withhold a percentage of the capitated payment to be paid based on performance.
- DHS will employ rigorous financial audits and other financial oversight strategies to ensure that IHAs are not experiencing significant profits or losses.