Implementation Matters: Lessons From Iowa Medicaid’s Healthy Behaviors Program

Iowa’s Medicaid expansion includes the Healthy Behaviors Program (HBP), which incentivizes enrollees to receive a wellness exam and complete a health risk assessment annually to waive a monthly premium. We conducted a telephone survey with enrollees to examine their awareness and understanding of the HBP, and we then merged the survey data with claims data to examine factors associated with the completion of program requirements. As found in previous research, awareness of the HBP remains low, with approximately half of respondents unaware of the program or the premium requirement. Our results suggest that four years after the program was implemented, requirements are not being effectively communicated to enrollees. When designing and implementing such programs, policy makers should note that they are unlikely to succeed without consideration of how the program is structured and promoted. Limited program awareness is likely to result in low participation and consequences related to paying premiums or being disenrolled.

Since the passage of the Affordable Care Act, states have used Section 1115 waivers to expand eligibility for Medicaid while implementing cost-sharing mechanisms or requiring premiums. States chose to incorporate these elements to improve health outcomes, reduce costs, and increase patients’ involvement in their own health care. For example, Indiana, Michigan, and Iowa encouraged Medicaid enrollees to engage in certain healthy behaviors, such as completing a wellness exam (defined as a medical or dental well visit), a health risk assessment, or both by offering incentives (such as contributions toward premium payments) or disincentives (for example, imposing a premium for people who did not engage in the specified behaviors). Indiana’s waiver requires a monthly premium for all expansion enrollees. Enrollees in Indiana who earn between 100 percent and 138 percent of the federal poverty level and fail to pay their premiums are disenrolled for six months. Enrollees who earn at or below 100 percent of poverty and fail to pay are moved to more basic coverage. Michigan’s program requires a monthly premium for enrollees who earn between 100 percent and 138 percent of poverty, which can be reduced by 50 percent by completing the healthy behavior program.

Early evaluations of the healthy behavior programs in Michigan and Indiana have not been particularly encouraging, reporting limited program awareness and low completion rates for required activities. Even before the Affordable Care Act, states such as West Virginia had redesigned their Medicaid programs to incorporate similar elements through the Deficit Reduction Act of 2005.9 West Virginia’s program suffered from implementation difficulties, limited awareness, and low participation—which collectively led to the end of the program.

The story is similar in Iowa. From the inception, Iowa’s Medicaid expansion, called the Iowa Health and Wellness Plan, has included a component called the Healthy Behaviors Program (HBP). Enrollees with incomes at or below 100 percent of poverty are enrolled in the Wellness Plan, a version of the traditional Medicaid state plan. Enrollees with incomes of 101–138 percent of poverty are enrolled in the Iowa Marketplace Choice Plan, which allows them to choose among private insurers that offer qualified Marketplace-based health plans. The HBP requires enrollees with incomes of 51–138 percent of poverty who do not complete both a wellness exam and a health risk assessment to pay an income-based premium of $5 or $10 a month. The wellness exam requirement can be fulfilled by completing either a medical or dental well visit. The health risk assessment must be completed by the enrollee and shared with a health care provider. While Iowa Medicaid is informed of a health risk assessment’s completion by the enrollee, health care provider, or managed care organization, the assessment is not shared with the state. Iowa Medicaid maintains data on wellness exam and health risk assessment completion derived from Medicaid claims and data reported by providers, managed care organizations, and enrollees. Enrollees with incomes at or above 101 percent of poverty who fail to pay their premiums face disenrollment.

Implementation of Iowa’s HBP has been challenging for numerous reasons. First, unexpected changes to Iowa’s insurance Marketplace caused issues and delays with the planned implementation, and Marketplace Choice enrollees were transitioned to the Wellness Plan. Second, the shift to Medicaid managed care, announced in January 2015, complicated HBP implementation. Enrollees were confused when the administration of the program shifted from the state to a trio of managed care organizations. This confusion has been compounded by significant turnover among the managed care organizations. Of the three original organizations, only one remains, and a new managed care organization has contracted with the state. Third, during the first two years of the program, HBP requirement completion rates were poor. According to analyses of claims data, over 80 percent of enrollees failed to comply with the requirements, potentially subjecting them to monthly premiums or disenrollment for nonpayment. Early evidence suggests that disenrolled people suffered stress, increased financial burdens, and delays in accessing care. Finally, the state was unable to fully implement the HBP, which was originally designed to include enrollee incentives for meeting additional healthy behavior goals beyond the wellness exam and health risk assessment.

While the struggles experienced in Iowa’s HBP may have been due to low program awareness among both enrollees and providers, more in-depth work is needed to better understand how the program has been implemented and more clearly describe enrollees’ experiences. We conducted a survey to assess enrollees’ awareness of the HBP, knowledge about its components, the source of that knowledge, self-reported completion of the HBP requirements, and the factors associated with completion of these requirements.