HF 83 (LSB 1441YH (2) 85)

HOUSE FILE 83

BY  HEDDENS, WESSEL-KROESCHELL, ISENHART, MURPHY, BERRY, GASKILL, HUNTER, WOOD, COHOON, DAWSON, M. SMITH, BEARINGER, KRESSIG, T. TAYLOR, STAED, MASCHER, OURTH, WINCKLER, STUTSMAN, THEDE, H. MILLER, ANDERSON, STECKMAN, HANSON, LENSING, OLDSON, and THOMAS

A BILL FOR

An Act relating to integrated care models for the delivery of health care, including but not limited to required utilization of a medical home by individuals currently and newly eligible for coverage under the Medicaid program and including effective date provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  Section 135.157, subsections 4 and 6, Code 2013, are amended to read as follows:
   4.  “Medical home” means a team approach to providing health care that originates in a primary care setting; fosters a partnership among the patient, the personal provider, and other health care professionals, and where appropriate, the patient’s family; utilizes the partnership to access
 
and integrate all medical and nonmedical health-related services
 
across all elements of the health care system and the patient’s community as needed by the patient and the patient’s family to achieve maximum health potential; maintains a centralized, comprehensive record of all health-related services to promote continuity of care; and has all of the characteristics specified in section 135.158.
   6.  “Personal provider” means the patient’s first point of contact in the health care system with a primary care provider who identifies the patient’s health
 
health-related needs and, working with a team of health care professionals
 
and providers of medical and nonmedical health-related services, provides for and coordinates appropriate care to address the health
 
health-related needs identified.
    Sec. 2.  Section 135.158, subsection 2, paragraphs b, c, and d, Code 2013, are amended to read as follows:
   b.  A provider-directed
 
team-based medical practice. The personal provider leads a team of individuals at the practice level who collectively take responsibility for the ongoing health care
 
health-related needs of patients.
   c.  Whole person orientation. The personal provider is responsible for providing for all of a patient’s health care
 
health-related needs or taking responsibility for appropriately arranging health care
 
for health-related services provided by other qualified health care professionals
 
and providers of medical and nonmedical health-related services. This responsibility includes health
 
health-related care at all stages of life including provision of
 
preventive care, acute care, chronic care, preventive services
 
long-term care, transitional care between providers and settings, and end-of-life care. 
 
This responsibility includes whole-person care consisting of physical health care including but not limited to oral, vision, and other specialty care, pharmacy management, and behavioral health care.
   d.  Coordination and integration of care. Care is coordinated and integrated across all elements of the complex health care system and the patient’s community. 
 
Care coordination and integration provides linkages to community and social supports to address social determinants of health, to engage and support patients in managing their own health, and to track the progress of these community and social supports in providing whole-person care. Care is facilitated by registries, information technology, health information exchanges, and other means to assure that patients receive the indicated care when and where they need and want the care in a culturally and linguistically appropriate manner.
    Sec. 3.  Section 135.159, subsections 1, 9, and 11, Code 2013, are amended to read as follows:
   1.  The department shall administer the medical home system. 
 
The department shall collaborate with the department of human services in administering medical homes under the medical assistance program. The department shall adopt rules pursuant to chapter 17A necessary to administer the medical home system, and shall collaborate with the department of human services in adopting rules for medical homes under the medical assistance program.
   9.  The department shall coordinate the requirements and activities of the medical home system with the requirements and activities of the dental home for children as described in section 249J.14, and shall recommend financial incentives for dentists and nondental providers to promote oral health care coordination through preventive dental intervention, early identification of oral disease risk, health care coordination and data tracking, treatment, chronic care management, education and training, parental guidance, and oral health promotions for children. 
 
Additionally, the department shall establish requirements for the medical home system to provide linkages to accessible dental homes for adults and older individuals.
   11.  Implementation phases.
   a.  Initial implementation shall
 
No later than July 1, 2014, the department shall collaborate with the department of human services to require participation in the medical home system of children
 
all of the following:
   (1)  Children
 
who are recipients of full benefits under the medical assistance program. The department shall work with the department of human services and shall recommend to the general assembly a reimbursement methodology to compensate providers participating under the medical assistance program for participation in the medical home system.
   b.

(2)  The department shall work with the department of human services to expand the medical home system to adults
 
Adults who are recipients of full benefits under the medical assistance program and the expansion population under the IowaCare program
 
including those adults who are recipients of benefits under section 249A.3, subsection 1, paragraph “v”, in accordance with the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 2001, as amended by the federal Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152.
   (3)  The department shall work with
 
Medicare and dually eligible Medicare and Medicaid recipients, to the extent approved by the centers for Medicare and Medicaid services of the United States department of health and human services to allow Medicare recipients to utilize the medical home system.
   c.

b.  The department shall work with the department of administrative services to allow state employees to utilize the medical home system.
   d.

c.  The department shall work with insurers and self-insured companies, if requested, to make the medical home system available to individuals with private health care coverage.
    Sec. 4.  Section 249A.3, subsection 1, Code 2013, is amended by adding the following new paragraph:
   NEW PARAGRAPH.  v.  Beginning January 1, 2014, is an individual who is nineteen years of age or older and under age sixty-five; is not pregnant; is not entitled to or enrolled for Medicare benefits under part A, or enrolled for Medicare benefits under part B, of Tit. XVIII of the federal Social Security Act; is not otherwise described in section 1902a(a)(10)(A)(i) of the federal Social Security Act; and whose income is at or below one hundred thirty-three percent of the federal poverty level as defined by the most recently revised poverty income guidelines published by the United States department of health and human services for the applicable family size and as calculated in accordance with the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 2001, as amended by the federal Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152. Individuals eligible for medical assistance under this paragraph shall receive benefits which are at a minimum those included in the medical assistance state plan benefit package offered in the state, to be adjusted as necessary to provide essential health benefits as required pursuant to section 1302 of the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and as approved by the United States secretary of health and human services.
    Sec. 5.  Section 249J.26, subsection 2, Code 2013, is amended to read as follows:
   2.  This chapter is repealed October
 
December 31, 2013. 
 
The department shall prepare a plan for the transition of expansion population members to other health care coverage options. The options shall include the option of coverage through the medical assistance program as provided in section 249A.3, subsection 1, paragraph “v”, relating to coverage for adults who are nineteen years of age or older and under age sixty-five, and the option of coverage through the health benefits exchange established pursuant to the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152. To the greatest extent possible, the plan shall maintain and incorporate utilization of the existing medical home and service delivery structure as developed under this chapter, including the utilization of federally qualified health centers, public hospitals, and other safety net providers, in providing access to care. The department shall submit the plan to the governor and the general assembly no later than September 1, 2013.
    Sec. 6.  LEGISLATIVE COMMISSION ON INTEGRATED CARE MODELS.
   1.  No later than thirty days after the effective date of this Act, the legislative council shall establish a legislative commission to review and make recommendations relating to the formation and operation of integrated care models (ICMs) in the state. The models include any care delivery model that integrates providers and incorporates a financial incentive to improve patient health outcomes, improve care, and reduce costs. Integrated care models include but are not limited to patient-centered medical homes or health homes, accountable care organizations (ACOs), ACO-like models, community and regional care networks, and other integrated and accountable delivery models that utilize value-based financing methodologies and emphasize person-centered, coordinated, and comprehensive care.
   2.
  a.  In developing the recommendations, the legislative commission shall review models created in other states that integrate both clinical services and nonclinical community and social supports utilizing patient-centered medical homes and community care teams as basic components. These models may include but are not limited to the ACO demonstration program based on the Camden Coalition of Healthcare Providers in Camden, New Jersey; the Medical Home Network in Chicago, Illinois; the Health Commons model in New Mexico; the Accountable Care Collaborative in Colorado; Community Care of North Carolina, in North Carolina; the Blueprint for Health and the Community Health Teams in Vermont; and the Coordinated Care Organizations in Oregon.
   b.  The legislative commission shall specifically focus on recommending the best means of providing care through integrated delivery models throughout the state including to vulnerable populations and how best to incorporate safety net providers, including but not limited to federally qualified health centers, rural health clinics, community mental health centers, public hospitals, and other nonprofit and public providers that have long experience in caring for vulnerable populations, into the integrated system.
   c.  The legislative commission shall review opportunities under the federal Patient Protection and Affordable Care Act (Affordable Care Act), Pub. L. No. 11-148, as amended, for the development of ICMs including the Medicare Shared Savings program for accountable care organizations, community-based collaborative care networks that include safety net providers, consumer-operated and oriented plans, and opportunities through the Center for Medicare and Medicaid Innovation (CMI) established pursuant to section 3021 of the Affordable Care Act. The legislative commission shall also review existing and proposed integrated care models in the state including commercial models and those developed or proposed under the Accountable Care Act including the Medicare Shared Savings Program, the Pioneer ACO, and the application for the multipayer Medicaid ACO developed through the CMI State Innovation Models Initiative.
   d.  The legislative commission shall address the issues relative to ICMs including those relating to consumer protection including those that relate to confidentiality, quality assurance, grievance procedures, and appeals of patient care decisions; payment methodologies, multipayer alignment, coordination of funding streams, and financing methods that support full integration of clinical and nonclinical services and providers; organizational, management, and governing structures; access, quality, outcomes, utilization, and other appropriate performance standards; patient attribution or assignment models; health information exchange, data, reporting, and infrastructure standards; and regulatory issues including clinical integration limitations, physician self-referral, antikickback provisions, gain-sharing, beneficiary inducements, antitrust issues, tax exemption issues, and application of insurance regulations.
   3.  The legislative commission shall consult with advocates representing patients, health care providers, health care payers, and other appropriate parties in developing the recommendations relating to ICMs.
   4.  The legislative commission may request from any state agency or official information and assistance as needed to perform the review and make recommendations.
   5.  The legislative commission shall submit a final report summarizing the legislative commission’s activities, analyzing the issues reviewed, and making recommendations to the governor and the general assembly by September 1, 2013.
    Sec. 7.  MEDICAID STATE PLAN.
   1.  The department of human services shall amend the medical assistance state plan to reflect the required provision of a medical home to medical assistance recipients as provided in this Act.
   2.  The department of human services shall amend the medical assistance state plan to provide for coverage of adults up to 133 percent of the federal poverty level as provided in this Act and in accordance with the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 2001, as amended by the federal Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152.
   3.  The department of human services shall amend the medical assistance state plan to provide that the benchmark benefit plan provided to the newly covered adults under the medical assistance program is the option of secretary-approved coverage which is at a minimum the Medicaid state plan benefit package offered in the state, to be adjusted as necessary to provide essential health benefits as required pursuant to section 1302(b) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148.
    Sec. 8.  EFFECTIVE UPON ENACTMENT.  This Act, being deemed of immediate importance, takes effect upon enactment.
EXPLANATION
   This bill relates to integrated health care delivery models.
   The bill amends provisions relating to medical homes to require a team-based, multidisciplinary approach to health care delivery. The bill requires the department of human services (DHS) to collaborate with the department of public health (DPH) in administering medical homes under the Medicaid program. The bill amends provisions relating to implementation of medical homes in the state by requiring all children and adults who are recipients of full benefits under the medical assistance program, including adults up to 133 percent of the federal poverty level who are eligible under the federal Patient Protection and Affordable Care Act (ACA), Pub. L. No. 111-148, § 2001, as amended by the federal Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, and individuals who are dually eligible to the extent approved by the centers for Medicare and Medicaid services of the United States department of health and human services (CMS), to participate in a medical home not later than July 1, 2014. The bill does not amend the Code provisions directing DPH to work with the department of administrative services to allow state employees to utilize the medical home system and to work with insurers and self-insured companies, if requested, to make the medical home system available to individuals with private health care coverage.
   The bill provides for Medicaid eligibility of certain adults with incomes at or below 133 percent of the federal poverty level in accordance with the ACA. Additionally, the bill requires that these newly eligible adults receive benefits which are included in the medical assistance state plan benefit package offered in the state as adjusted to provide the essential health benefits required under the ACA, and as approved by the United States secretary of health and human services.
   The bill directs the legislative council to establish a legislative commission to review and make recommendations for the formation and operation of integrated care models (ICM) in the state. The bill describes ICMs as any care delivery model that integrates providers and incorporates a financial incentive to improve patient health outcomes, improve care, and reduce costs. ICMs include but are not limited to patient-centered medical homes or health homes, accountable care organizations (ACOs), ACO-like models, and other integrated and accountable health delivery models that utilize value-based financing methodologies and emphasize person-centered, coordinated, comprehensive care. The legislative commission is directed to consult with advocates representing patients, health care providers, health care payers, and other appropriate parties in developing the recommendations for ICMs; to specifically address certain issues to review existing ICMs in other states as well as those existing or proposed in the state Medicare Shared Savings Program, the Pioneer ACO, and the Center for Medicare and Medicaid Innovation State Innovation Models Initiative application to implement a multipayer ACO including Medicaid. The legislative commission is required to make its recommendations to the governor and the general assembly by September 1, 2013. 
   The bill requires DHS to amend the medical assistance state plan to implement the bill with respect to the provision of medical homes and the coverage of certain low-income adults.
   The bill takes effect upon enactment.