House File 2244 - Introduced HOUSE FILE 2244 BY HEDDENS , HUNTER , KRESSIG , STAED , P. MILLER , GASKILL , STECKMAN , WINCKLER , McCONKEY , BEARINGER , KEARNS , BRECKENRIDGE , HALL , PRICHARD , COHOON , ISENHART , OLDSON , KURTH , OURTH , and T. TAYLOR A BILL FOR An Act relating to the Medicaid program, including long-term 1 services and supports, integrated health homes, capitation 2 and reimbursement rates, and oversight, and including 3 effective date provisions. 4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 5 TLSB 5730YH (7) 87 pf/rh

H.F. 2244 Section 1. TERMINATION OF MEDICAID MANAGED CARE CONTRACTS 1 RELATIVE TO LONG-TERM SERVICES AND SUPPORTS POPULATION —— 2 TRANSITION TO FEE-FOR-SERVICE. The department of human 3 services shall, upon the effective date of this Act, provide 4 written notice in accordance with the termination provisions 5 of the contract, to each managed care organization with whom 6 the department executed a contract to administer the Iowa 7 high quality health care initiative as established by the 8 department, to terminate such contracts as applicable to 9 the Medicaid long-term services and supports population, 10 following a sixty-day transition period. The department shall 11 transfer the long-term services and supports population to 12 fee-for-service program administration. The transition shall 13 be based on a transition plan developed by the department and 14 submitted to the council on human services and the medical 15 assistance advisory council for review. 16 Sec. 2. INTEGRATED HEALTH HOME FOR PERSONS WITH SERIOUS AND 17 PERSISTENT MENTAL ILLNESS (SPMI INTEGRATED HEALTH HOME). The 18 department of human services shall adopt rules pursuant to 19 chapter 17A and shall amend existing Medicaid managed care 20 contracts to carve out SPMI integrated health homes services 21 as specified in the Medicaid state plan amendment, IA-16-013, 22 from Medicaid managed care contracts and instead provide SPMI 23 integrated health home services through the fee-for-service 24 payment and delivery system. 25 Sec. 3. RECALCULATION OF CERTAIN CAPITATION RATES UNDER 26 MEDICAID MANAGED CARE. For the fiscal year beginning July 27 1, 2018, the department of human services shall utilize 28 Medicaid program claims paid data for the period beginning 29 April 1, 2015, and ending March 31, 2016, as base data to 30 develop and certify capitation rates for providers of home and 31 community-based intellectual disability waiver services under 32 Medicaid managed care. 33 Sec. 4. MEDICAID MANAGED CARE OVERSIGHT. The department of 34 human services shall amend the Medicaid managed care contracts 35 -1- LSB 5730YH (7) 87 pf/rh 1/ 7

H.F. 2244 and adopt rules pursuant to chapter 17A to provide that 1 beginning July 1, 2018, all of the following shall apply: 2 1. MEMBER STATUS CHANGES. 3 a. A Medicaid managed care organization shall provide prior 4 notice, in writing, to a member and to any affected provider, 5 of any change in the status of the member at least thirty 6 days prior to the effective date of the change in status. If 7 notification is not received by the provider and the member 8 continues to receive services from the provider, the Medicaid 9 managed care organization shall reimburse the provider for 10 services rendered. 11 b. If a member transfers from one managed care organization 12 to another, the managed care organization from which the 13 member is transferring shall forward the member’s records to 14 the managed care organization assuming the member’s coverage 15 at least thirty days prior to the managed care organization 16 assuming such coverage. 17 c. If a provider provides services to a member for which the 18 member is eligible while awaiting any necessary authorization, 19 and the authorization is subsequently approved, the provider 20 shall be reimbursed at the contracted rate for any services 21 provided prior to receipt of the authorization. 22 2. DATA. Managed care organizations shall report to the 23 department of human services not only the percentage of medical 24 and pharmacy clean claims paid or denied within a certain 25 time frame, but shall also report all of the following on a 26 quarterly basis: 27 a. The total number of original medical and pharmacy claims 28 submitted to the managed care organization. 29 b. The total number of original medical and pharmacy claims 30 deemed rejected and the reason for rejection. 31 c. The total number of original medical and pharmacy claims 32 deemed suspended, the reason for suspension, and the number of 33 days from suspension to submission for processing. 34 d. The total number of original medical and pharmacy 35 -2- LSB 5730YH (7) 87 pf/rh 2/ 7

H.F. 2244 claims initially deemed either rejected or suspended that are 1 subsequently deemed clean claims and paid, and the average 2 number of days from initial submission to payment of the clean 3 claim. 4 e. The total number of medical and pharmacy claims that 5 are outstanding for thirty, sixty, ninety, one hundred eighty, 6 or more than one hundred eighty days, and the total amount 7 attributable to these outstanding claims if paid as submitted. 8 f. The total amount requested as payment for all original 9 medical or pharmacy claims versus the total amount actually 10 paid as clean claims and the total amount of payment denied. 11 g. The total number of original medical and pharmacy claims 12 received, the number of such claims for which one hundred 13 percent of the requested amount was paid, the number of such 14 claims for which less than one hundred percent of the requested 15 amount was paid and the percentage actually paid, and the total 16 dollar amount of payments denied. 17 3. REIMBURSEMENT. For the fiscal year beginning July 1, 18 2018, Medicaid providers or services shall be reimbursed as 19 follows: 20 a. For fee-for-service claims, reimbursement shall be 21 calculated based on the methodology in effect on June 30, 2018, 22 for the respective provider or service. 23 b. For claims subject to a managed care contract: 24 (1) Reimbursement shall be based on the methodology 25 established by the managed care contract. However, any 26 reimbursement established under such contract shall not be 27 lower than the rate floor established by the department of 28 human services as the managed care organization provider or 29 service reimbursement rate floor for the respective provider or 30 service in effect on June 30, 2018. 31 (2) For any provider or service to which a reimbursement 32 increase is applicable for the fiscal year under state law, 33 upon the effective date of the reimbursement increase, the 34 department of human services shall modify the rate floor in 35 -3- LSB 5730YH (7) 87 pf/rh 3/ 7

H.F. 2244 effect on June 30, 2018, to reflect the increase specified. 1 Any reimbursement established under the managed care contract 2 shall not be lower than the rate floor as modified by the 3 department of human services to reflect the provider rate 4 increase specified. 5 (3) Any reimbursement established between the managed 6 care organization and the provider shall be in effect for at 7 least twelve months from the date established, unless the 8 reimbursement is increased. A reimbursement rate that is 9 negotiated and established above the rate floor shall not be 10 decreased from that amount for at least twelve months from the 11 date established. 12 4. PRIOR AUTHORIZATION. 13 a. Any change by a Medicaid managed care organization in a 14 requirement for prior authorization for a prescription drug or 15 service shall be preceded by the provision of sixty days’ prior 16 written notice published on the managed care organization’s 17 internet site and provided in writing to all affected members 18 and providers before the effective date of the change. 19 b. Each managed care organization shall post to the managed 20 care organization’s internet site prior authorization data 21 including but not limited to statistics on approvals and 22 denials of prior authorization requests by physician specialty, 23 medication, test, procedure, or service, the indication 24 offered, and if denied, the reason for denial. 25 Sec. 5. MEDICAID STATE PLAN OR WAIVER AMENDMENTS. The 26 department of human services shall seek any Medicaid state plan 27 or waiver amendments necessary to administer this Act. 28 Sec. 6. EFFECTIVE DATE. This Act, being deemed of immediate 29 importance, takes effect upon enactment. 30 EXPLANATION 31 The inclusion of this explanation does not constitute agreement with 32 the explanation’s substance by the members of the general assembly. 33 This bill directs the department of human services (DHS) 34 to provide written notice in accordance with the termination 35 -4- LSB 5730YH (7) 87 pf/rh 4/ 7

H.F. 2244 provisions of the contract, to each managed care organization 1 (MCO) with whom DHS executed a contract to administer the Iowa 2 high quality health care initiative as established by the 3 department, to terminate such contracts as applicable to the 4 long-term services and supports population, following a 60-day 5 transition period. DHS is directed to transfer the long-term 6 services and supports population to fee-for-service program 7 administration. The transition is to be based on a transition 8 plan developed by the department and submitted to the council 9 on human services and the medical assistance advisory council 10 for review. 11 The bill requires DHS to adopt rules pursuant to Code chapter 12 17A and to amend existing Medicaid managed care contracts to 13 carve out SPMI integrated health homes services as specified 14 in the Medicaid state plan amendment, IA-16-013, from Medicaid 15 managed care contracts and instead provide SPMI integrated 16 health home services through the fee-for-service payment and 17 delivery system. 18 The bill requires DHS to use Medicaid program claims paid 19 data for the period beginning April 1, 2015, and ending March 20 31, 2016, as base data to develop and certify capitation 21 rates for providers of home and community-based intellectual 22 disability waiver services under Medicaid managed care for the 23 fiscal year beginning July 1, 2018. 24 The bill provides for Medicaid managed care oversight. The 25 bill requires DHS to amend the Medicaid managed care contracts 26 and adopt rules pursuant to Code chapter 17A to provide for a 27 number of changes, beginning July 1, 2018. 28 The bill requires MCOs to provide prior written notice to a 29 member and to any affected provider of any change in the status 30 of the member that affects such provider at least 30 days prior 31 to the effective date of the change in status. If notification 32 is not received by the provider and the member continues to 33 receive services from the provider, the MCO shall reimburse the 34 provider for services rendered. If a member transfers from one 35 -5- LSB 5730YH (7) 87 pf/rh 5/ 7

H.F. 2244 MCO to another, the MCO from which the member is transferring 1 shall forward the member’s records to the MCO assuming the 2 member’s coverage at least 30 days prior to the MCO assuming 3 such coverage. Additionally, if a provider provides services 4 to a member for which the member is eligible while the provider 5 is awaiting any necessary authorization to provide the service, 6 and the authorization is subsequently approved, the provider 7 shall be reimbursed at the contracted rate for any services 8 provided prior to receipt of the authorization. 9 With regard to data, the bill requires that MCOs, in addition 10 to reporting to DHS the percentage of medical and pharmacy 11 clean claims paid or denied within a certain time frame, to 12 also report additional data regarding claims as specified in 13 the bill on a quarterly basis. 14 With regard to reimbursement, the bill requires 15 reimbursement beginning July 1, 2018, for Medicaid providers 16 and services, to be calculated based on the methodology 17 in effect on June 30, 2018, for the respective provider or 18 service for fee-for-service claims and for claims subject to 19 a managed care contract, reimbursement shall be based on the 20 methodology established by the managed care contract. However, 21 any reimbursement established under such contract shall not be 22 lower than the rate floor established by DHS as a rate floor 23 for the respective provider or service in effect on June 30, 24 2018. Additionally, for any provider or service to which a 25 reimbursement increase is applicable for the fiscal year under 26 state law beginning July 1, 2018, upon the effective date of 27 the reimbursement increase, DHS shall modify the rate floor in 28 effect on June 30, 2018, to reflect the increase specified and 29 any reimbursement established under the managed care contract 30 shall not be lower than the rate floor as modified. Any 31 reimbursement established between the managed care organization 32 and the provider shall be in effect for at least 12 months from 33 the date established, unless the reimbursement is increased. A 34 reimbursement rate negotiated and established above the rate 35 -6- LSB 5730YH (7) 87 pf/rh 6/ 7

H.F. 2244 floor shall not be decreased from that negotiated amount for at 1 least a 12-month period. 2 With regard to prior authorization, the bill requires that 3 any change by an MCO in a requirement for prior authorization 4 for a prescription drug or service shall be preceded by 60 5 days’ prior written notice published on the MCO’s internet site 6 and provided in writing to all affected members and providers 7 before the effective date of the change. The bill requires 8 an MCO to place certain prior authorization data on the MCO’s 9 internet site. 10 The bill requires DHS to seek any Medicaid state plan or 11 waiver amendments necessary to administer the bill. 12 The bill takes effect upon enactment. 13 -7- LSB 5730YH (7) 87 pf/rh 7/ 7