HF 2264 (LSB 5854YH (4) 87)

HOUSE FILE 2264

BY  HEATON

A BILL FOR

An Act relating to Medicaid managed care oversight including issues related to network adequacy, home and community-based services waiver services, member eligibility, and appeals processes.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  MEDICAID MANAGED CARE OVERSIGHT.
   1.  Because access to services is of critical importance to the vulnerable Medicaid populations receiving long-term services and supports, the network of long-term services and supports providers under contract with each managed care organization on January 1, 2018, shall be deemed necessary to meet the requirement for network adequacy. Any willing provider under contract on that date shall remain a network provider as long as the network provider complies with Medicaid state plan requirements for that provider. The rates in effect for each such provider on January 1, 2018, shall serve as the rate floor for such provider through June 30, 2019, unless the rate floors are otherwise amended or scheduled to be amended by law. The department of human services shall adopt rules pursuant to chapter 17A and shall amend all Medicaid managed care contracts as necessary to administer this subsection.
   2.  The department of human services shall adopt rules pursuant to chapter 17A and shall amend all Medicaid managed care contracts as necessary to provide for a process, under both the Medicaid fee-for-service and managed care reimbursement and services delivery methodologies, for reconsideration of a Medicaid member’s supports intensity scale (SIS) assessment score if a member, a member’s authorized representative, or a provider acting on behalf of the member disputes the accuracy or adequacy of the assessment score. The reconsideration process shall provide for an expedited first-level review by the applicable Medicaid managed care organization, followed by an appeals process in accordance with contested case proceedings pursuant to chapter 17A if the member, the member’s authorized representative, or a provider acting on behalf of the member is dissatisfied with the notice of decision resulting from the managed care organization’s review. The rules adopted and the amendment to any Medicaid managed care contract shall require that the expedited first-level review be completed and the notice of decision be issued by the managed care organization within 30 days of receipt by the managed care organization of the request for reconsideration. 
   3.  The department of human services and all Medicaid managed care organizations under contract with the state shall maintain and update member eligibility files in a timely manner. Medicaid providers who, in good faith, provide services to members in accordance with service plans and reimbursement agreements, shall not be denied payment for services rendered. Additionally, under such circumstances, payments shall not be recouped by the department or a managed care organization if, subsequent to the provision of such services, the managed care organization or the department determines that the member was not eligible for such services and if the provider of services is able to demonstrate, based on the information available to the provider, that the services were authorized at the time the services were rendered. The department of human services shall adopt rules pursuant to chapter 17A and shall amend all Medicaid managed care contracts to administer this subsection. 
   4.  The department of human services shall adopt rules pursuant to chapter 17A and shall amend all Medicaid managed care contracts to provide that if a Medicaid member prevails in a first-level review by the Medicaid managed care organization or on appeal in an action regarding provision of services, the services subject to the review or appeal shall be extended for not less than six months following the date of the decision. However, services shall not be extended if there is a change in the member’s condition that warrants a change in services as determined by the member’s interdisciplinary team, there is a change in the member’s eligibility status as determined by the department, or the member voluntarily withdraws from services. 
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to Medicaid managed care oversight.
   With regard to network adequacy, the bill requires that the network of long-term services and supports providers under contract with each managed care organization (MCO) on January 1, 2018, shall be deemed necessary to meet the requirement for network adequacy, and any willing provider under contract on that date shall remain a network provider as long as the network provider remains in compliance with Medicaid state plan requirements for that provider. Additionally, the rates in effect for each such provider on January 1, 2018, shall serve as the rate floor for such provider through June 30, 2019, unless the rate floors are amended or scheduled to be amended by law. 
   With regard to supports intensity scale (SIS) assessments, the bill requires provision of a process, under both Medicaid fee-for-service and managed care for reconsideration of a Medicaid member’s SIS assessment score if a member, a member’s authorized representative, or a provider acting on behalf of the member disputes the accuracy or adequacy of the assessment score. The reconsideration process must provide for an expedited first-level review by the applicable MCO followed by an appeals process in accordance with contested case proceedings if the member, the member’s authorized representative, or a provider acting on behalf of the member is dissatisfied with the notice of decision resulting from the MCO’s review. The expedited first-level review must be completed and the notice of decision must be issued by the MCO within 30 days of receipt of the request for reconsideration. 
   With regard to Medicaid member eligibility, the bill requires the department of human services (DHS) and all MCOs under contract with the state to maintain and update member eligibility files in a timely manner. Medicaid providers who, in good faith, provide services to members in accordance with service plans and reimbursement agreements shall not be denied payment for services rendered. Additionally, under such circumstances, DHS and the MCOs are prohibited from not paying or recouping payments to such providers if, subsequent to the provision of services, DHS or an MCO determines that the member was not eligible for such services and if the provider is able to demonstrate, based on the information available to the provider, that the services were authorized at the time the services were rendered. 
   With regard to member appeals regarding the provision of services, the bill also requires that if a Medicaid member prevails in a first-level review by the MCO or on appeal, the services subject to the review or appeal must be extended for not less than six months following the date of the decision. However, the services are not required to be extended if there is a change in the member’s condition that warrants a change in services as determined by the member’s interdisciplinary team, there is a change in the member’s eligibility status as determined by DHS, or the member voluntarily withdraws from services. 
   With regard to each requirement or provision under the bill, DHS is required to adopt administrative rules and amend Medicaid managed care contracts to administer the requirement or provision.