SF 420 (LSB 2687XS (3) 88)

SENATE FILE 420

BY  R. SMITH

A BILL FOR

An Act relating to processes and assistance under the Medicaid program.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

DIVISION I
MEDICAID PRIOR AUTHORIZATION

    Section 1.  MEDICAID —— PRIOR AUTHORIZATION UNIFORM PROCESS.  The department of human services shall adopt rules pursuant to chapter 17A to require, and shall contractually require, that both managed care and fee-for-service payment and delivery systems utilize a uniform process, including but not limited to uniform forms, information requirements, and time frames, to request prior authorization under the Medicaid program. 
DIVISION II
MEDICAID PROGRAM OMBUDSMAN

    Sec. 2.  NEW SECTION.  2C.6A  Assistant for Medicaid program.
   1.  The ombudsman shall appoint an assistant who shall be primarily responsible for investigating complaints relating to the Medicaid program, including both Medicaid fee-for-service and managed care payment and delivery systems, and all Medicaid populations including the long-term services and supports population.
   2.  The ombudsman shall provide assistance and advocacy services to Medicaid recipients and the families or legal representatives of Medicaid recipients. Such assistance and advocacy shall include but is not limited to all of the following: 
   a.  Assisting recipients in understanding the services, coverage, and access provisions and their rights under the Medicaid program.
   b.  Developing procedures for the tracking and reporting of the outcomes of individual requests for assistance, the procedures available for obtaining services, and other aspects of the services provided to Medicaid recipients.
   c.  Providing advice and assistance relating to the preparation and filing of complaints, grievances, and appeals of complaints or grievances, including through processes available under managed care plans and the state appeals process under the Medicaid program.
   3.  The ombudsman shall adopt rules to administer this section.
   4.  The ombudsman shall publish special reports and investigative reports as deemed necessary and shall include findings and recommendations related to the assistance and advocacy provided under this section in the ombudsman’s annual report. 
   5.  The ombudsman and the department of human services shall collaborate to develop a cost allocation plan requesting Medicaid administrative funding to provide for the claiming of federal financial participation for ombudsman activities that are performed to assist with the administration of the Medicaid program. The cost allocation plan shall document the costs that directly benefit the Medicaid program and are consistent with federal requirements. The cost allocation plan shall be developed in a timely manner to allow for such claiming to begin by January 1, 2020.
    Sec. 3.  REPEAL.  Section 231.44, Code 2019, is repealed.
DIVISION III
MEDICAID MANAGED CARE —— EXTERNAL REVIEW OF PROVIDER-DENIED CLAIMS

    Sec. 4.  MEDICAID MANAGED CARE —— EXTERNAL REVIEW OF PROVIDER-DENIED CLAIMS.
   1.  The department of human services shall contractually require a Medicaid managed care organization to utilize an external review process in accordance with rules adopted by the department pursuant to chapter 17A. The external review process shall provide for review by an independent third party of a Medicaid provider’s claims denied by the Medicaid managed care organization and following a final adverse determination of the managed care organization’s internal appeal process.
   2.  The external review process shall provide for all of the following:
   a.  A request for an external review shall automatically extend the deadline to file an appeal for a contested case hearing under chapter 17A, pending the outcome of the external review, until thirty calendar days following receipt of the final decision by the Medicaid provider.
   b.  Upon receipt of a request from a Medicaid provider for external review, the department shall assign the review to an external independent third-party reviewer, and notify the applicable Medicaid managed care organization and the Medicaid provider of the identity of the external reviewer.
   c.  Within fifteen calendar days of notification of a Medicaid provider’s request for external review, the managed care organization shall submit to the external reviewer all documentation submitted by the Medicaid provider in the course of the internal appeal process.
   d.  Within thirty calendar days of receiving all documentation from the applicable Medicaid managed care organization submitted by the Medicaid provider in the course of the internal appeal process, the external reviewer shall issue a final decision to the Medicaid provider, the applicable Medicaid managed care organization, and the department. The reviewer may extend the time to issue a final decision by fourteen calendar days upon agreement of all parties to the review. 
   e.  A party may appeal a final decision of the external reviewer in a contested case proceeding in accordance with chapter 17A within thirty calendar days from receipt of the final decision by the Medicaid provider. A final decision in a contested case proceeding is subject to judicial review.
   3.  The department shall enter into a contract with a review organization that does not have a conflict of interest with the department or any managed care organization to conduct the independent third-party reviews under this section.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   Division I of this bill requires the department of human services (DHS) to adopt administrative rules to require, and to contractually require, that both managed care and fee-for-service payment and delivery systems utilize a uniform process, including but not limited to uniform forms, information requirements, and time frames, to request prior authorization under the Medicaid program. 
   Division II of the bill directs the ombudsman to appoint an assistant who shall be primarily responsible for investigating complaints relating to the Medicaid program, including both the Medicaid managed care and fee-for-service payment and delivery systems, and all Medicaid populations including the long-term services and supports population. The division specifies the minimum areas of assistance and advocacy to be provided, directs the ombudsman to adopt administrative rules for administration of the division, and directs the ombudsman to publish special reports and investigative reports as deemed necessary, and to include findings and recommendations related to the Medicaid program assistance and advocacy provided under the division in the ombudsman’s annual report. 
   The division also repeals the section of the Code that directs the office of long-term care ombudsman to provide assistance and advocacy services to members of the Medicaid long-term services and supports population since under the division, the ombudsman will provide assistance and advocacy for both Medicaid managed care and fee-for-service payment and delivery systems and for all populations including the long-term services and supports population. 
   The division also requires the ombudsman and DHS to collaborate to develop a cost allocation plan, consistent with federal requirements, requesting Medicaid administrative funding to provide for the claiming of federal financial participation, by January 1, 2020, for ombudsman activities that are performed to assist with administration of the Medicaid program. 
   Division III of the bill requires DHS to contractually require a Medicaid managed care organization (MCO) to utilize an external review process in accordance with administrative rules adopted by DHS, to provide for a review by an independent third-party reviewer of a Medicaid provider’s claims denied by an MCO and following a final adverse determination of the MCO’s internal appeal process. The bill specifies what the external review process, at a minimum, shall provide for, and directs DHS to enter into a contract with a review organization that does not have a conflict of interest with DHS or any MCO to conduct the independent third-party reviews under the bill.