H.F. 2483 DIVISION I 1 SHARING OF INCARCERATION DATA 2 Section 1. Section 249A.38, Code 2018, is amended to read 3 as follows: 4 249A.38 Inmates of public institutions —— suspension or 5 termination of medical assistance. 6 1. The following conditions shall apply to Following the 7 first thirty days of commitment, the department shall suspend 8 the eligibility of an individual who is an inmate of a public 9 institution as defined in 42 C.F.R. §435.1010 , who is enrolled 10 in the medical assistance program at the time of commitment to 11 the public institution, and who remains eligible for medical 12 assistance as an individual except for the individual’s 13 institutional status : 14 a. The department shall suspend the individual’s 15 eligibility for up to the initial twelve months of the period 16 of commitment. The department shall delay the suspension 17 of eligibility for a period of up to the first thirty days 18 of commitment if such delay is approved by the centers for 19 Medicare and Medicaid services of the United States department 20 of health and human services. If such delay is not approved, 21 the department shall suspend eligibility during the entirety 22 of the initial twelve months of the period of commitment. 23 Claims submitted on behalf of the individual under the medical 24 assistance program for covered services provided during the 25 delay period shall only be reimbursed if federal financial 26 participation is applicable to such claims. 27 b. The department shall terminate an individual’s 28 eligibility following a twelve-month period of suspension 29 of the individual’s eligibility under paragraph “a” , during 30 the period of the individual’s commitment to the public 31 institution . 32 2. a. A public institution shall provide the department and 33 the social security administration with a monthly report of the 34 individuals who are committed to the public institution and of 35 -1- HF 2483 (4) 87 pf/rh/md 1/ 8

H.F. 2483 the individuals who are discharged from the public institution. 1 The monthly report to the department shall include the date 2 of commitment or the date of discharge, as applicable, of 3 each individual committed to or discharged from the public 4 institution during the reporting period. The monthly report 5 shall be made through the reporting system created by the 6 department for public, nonmedical institutions to report inmate 7 populations. Any medical assistance expenditures, including 8 but not limited to monthly managed care capitation payments, 9 provided on behalf of an individual who is an inmate of a 10 public institution but is not reported to the department 11 in accordance with this subsection, shall be the financial 12 responsibility of the respective public institution. 13 b. The department shall provide a public institution with 14 the forms necessary to be used by the individual in expediting 15 restoration of the individual’s medical assistance benefits 16 upon discharge from the public institution. 17 3. This section applies to individuals as specified in 18 subsection 1 on or after January 1, 2012. 19 4. 3. The department may adopt rules pursuant to chapter 20 17A to implement this section. 21 DIVISION II 22 MEDICAID PROGRAM ADMINISTRATION 23 Sec. 2. MEDICAID PROGRAM ADMINISTRATION. 24 1. PROVIDER PROCESSES AND PROCEDURES. 25 a. When all of the required documents and other information 26 necessary to process a claim have been received by a managed 27 care organization, the managed care organization shall 28 either provide payment to the claimant within the timelines 29 specified in the managed care contract or, if the managed 30 care organization is denying the claim in whole or in part, 31 shall provide notice to the claimant including the reasons for 32 such denial consistent with national industry best practice 33 guidelines. 34 b. If a managed care organization discovers that a claims 35 -2- HF 2483 (4) 87 pf/rh/md 2/ 8

H.F. 2483 payment barrier is the result of a managed care organization’s 1 identified system configuration error, the managed care 2 organization shall correct such error and shall fully and 3 accurately reprocess the claims affected by the error within 4 thirty days of such discovery or within a time frame approved 5 by the department. For the purposes of this paragraph, 6 “configuration error” means an error in provider data, an 7 incorrect fee schedule, or an incorrect claims edit. 8 c. The department of human services shall provide for 9 the development and require the use of standardized Medicaid 10 provider enrollment forms to be used by the department and 11 uniform Medicaid provider credentialing standards to be used 12 by managed care organizations. The credentialing process is 13 deemed to begin when the managed care organization has received 14 all necessary credentialing materials from the provider and is 15 deemed to have ended when written communication is mailed or 16 faxed to the provider notifying the provider of the managed 17 care organization’s decision. 18 d. A managed care organization shall provide written notice 19 to all affected individuals at least sixty days prior to a 20 significant change in administrative procedures relating to 21 the scope or coverage of benefits, billings and collections 22 provisions, provider network provisions, member or provider 23 services, prior authorization requirements, or any other terms 24 of a managed care contract or agreement as determined by the 25 department of human services. A managed care organization may 26 comply with the requirement of providing written notice under 27 this paragraph by posting such written notice on the managed 28 care organization’s internet site. 29 e. The department of human services shall engage dedicated 30 provider relations staff to assist Medicaid providers in 31 resolving billing conflicts with managed care organizations 32 including those involving denied claims, technical omissions, 33 or incomplete information. If the provider relations staff 34 observe trends evidencing fraudulent claims or improper 35 -3- HF 2483 (4) 87 pf/rh/md 3/ 8

H.F. 2483 reimbursement, the staff shall forward such evidence to the 1 department of human services for further review. 2 f. The department of human services shall adopt rules 3 pursuant to chapter 17A to require the inclusion by a managed 4 care organization of advanced registered nurse practitioners 5 and physician assistants as primary care providers for the 6 purposes of population health management. 7 2. MEMBER SERVICES AND PROCESSES. 8 a. If a Medicaid member prevails on appeal regarding the 9 provision of services, the services subject to the appeal 10 shall be extended for a period of time determined by the 11 director of human services. However, services shall not be 12 extended if there is a change in the member’s condition that 13 warrants a change in services as determined by the member’s 14 interdisciplinary team, there is a change in the member’s 15 eligibility status as determined by the department of human 16 services, or the member voluntarily withdraws from services. 17 b. If a Medicaid member is receiving court-ordered services 18 or treatment for a substance-related disorder pursuant to 19 chapter 125 or for a mental illness pursuant to chapter 229, 20 such services or treatment shall be provided and reimbursed 21 for an initial period of three days before a managed care 22 organization may apply medical necessity criteria to determine 23 the most appropriate services, treatment, or placement for the 24 Medicaid member. 25 c. The department of human services shall review and have 26 approval authority for level of care reassessments for Medicaid 27 long-term services and supports (LTSS) population members that 28 indicate a decrease in the level of care. A managed care 29 organization shall comply with the findings of the departmental 30 review and approval of such level of care reassessments. If 31 a level of care reassessment indicates there is no change in 32 a Medicaid LTSS population member’s level of care needs, the 33 Medicaid LTSS population member’s existing level of care shall 34 be continued. A managed care organization shall maintain 35 -4- HF 2483 (4) 87 pf/rh/md 4/ 8

H.F. 2483 and make available to the department of human services all 1 documentation relating to a Medicaid LTSS population member’s 2 level of care assessment. 3 d. The department of human services shall maintain and 4 update Medicaid member eligibility files in a timely manner 5 consistent with national industry best practices. 6 3. MEDICAID PROGRAM REVIEW AND OVERSIGHT. 7 a. (1) The department of human services shall facilitate a 8 workgroup, in collaboration with representatives of the managed 9 care organizations and health home providers, to review the 10 health home programs. The review shall include all of the 11 following: 12 (a) An analysis of the state plan amendments applicable to 13 health homes. 14 (b) An analysis of the current health home system, including 15 the rationale for any recommended changes. 16 (c) The development of a clear and consistent delivery 17 model linked to program-determined outcomes and data reporting 18 requirements. 19 (d) A work plan to be used in communicating with 20 stakeholders regarding the administration and operation of the 21 health home programs. 22 (2) The department of human services shall submit a report 23 of the workgroup’s findings and recommendations by December 24 15, 2018, to the governor and to the Eighty-eighth General 25 Assembly, 2019 session, for consideration. 26 (3) The workgroup and the workgroup’s activities shall 27 not affect the department’s authority to apply or enforce the 28 Medicaid state plan amendment relative to health homes. 29 b. The department of human services, in collaboration 30 with Medicaid providers and managed care organizations, shall 31 initiate a review process to determine the effectiveness of 32 prior authorizations used by the managed care organizations 33 with the goal of making adjustments based on relevant 34 service costs and member outcomes data utilizing existing 35 -5- HF 2483 (4) 87 pf/rh/md 5/ 8

H.F. 2483 industry-accepted standards. Prior authorization policies 1 shall comply with existing rules, guidelines, and procedures 2 developed by the centers for Medicare and Medicaid services of 3 the United States department of health and human services. 4 c. The department of human services shall enter into a 5 contract with an independent auditor to perform an audit of a 6 random sample of small dollar claims paid to or denied Medicaid 7 long-term services and supports providers during the first 8 quarter of the 2018 calendar year. The department of human 9 services shall submit a report of the findings of the audit to 10 the governor and the general assembly by December 15, 2018. 11 The department may take any action specified in the managed 12 care contract relative to any claim the auditor determines to 13 be incorrectly paid or denied, subject to appeal by the managed 14 care organization to the director of human services. For the 15 purposes of this paragraph, “small dollar claims” means those 16 claims less than or equal to two thousand five hundred dollars. 17 DIVISION III 18 MEDICAID PROGRAM PHARMACY COPAYMENT 19 Sec. 3. 2005 Iowa Acts, chapter 167, section 42, is amended 20 to read as follows: 21 SEC. 42. COPAYMENTS FOR PRESCRIPTION DRUGS UNDER THE 22 MEDICAL ASSISTANCE PROGRAM. The department of human services 23 shall require recipients of medical assistance to pay the 24 following copayments a copayment of $1 on each prescription 25 filled for a covered prescription drug, including each refill 26 of such prescription , as follows: 27 1. A copayment of $1 on each prescription filled for each 28 covered nonpreferred generic prescription drug . 29 2. A copayment of $1 for each covered preferred brand–name 30 or generic prescription drug. 31 3. A copayment of $1 for each covered nonpreferred 32 brand–name prescription drug for which the cost to the state is 33 up to and including $25. 34 4. A copayment of $2 for each covered nonpreferred 35 -6- HF 2483 (4) 87 pf/rh/md 6/ 8

H.F. 2483 brand–name prescription drug for which the cost to the state is 1 more than $25 and up to and including $50. 2 5. A copayment of $3 for each covered nonpreferred 3 brand–name prescription drug for which the cost to the state 4 is more than $50. 5 DIVISION IV 6 MEDICAL ASSISTANCE ADVISORY COUNCIL 7 Sec. 4. Section 249A.4B, subsection 2, paragraph a, 8 subparagraphs (27) and (28), Code 2018, are amended by striking 9 the subparagraphs. 10 Sec. 5. MEDICAL ASSISTANCE ADVISORY COUNCIL —— REVIEW OF 11 MEDICAID MANAGED CARE REPORT DATA. The executive committee 12 of the medical assistance advisory council shall review 13 the data collected and analyzed for inclusion in periodic 14 reports to the general assembly, including but not limited 15 to the information and data specified in 2016 Iowa Acts, 16 chapter 1139, section 93, to determine which data points and 17 information should be included and analyzed to more accurately 18 identify trends and issues with, and promote the effective and 19 efficient administration of, Medicaid managed care for all 20 stakeholders. At a minimum, the areas of focus shall include 21 consumer protection, provider network access and safeguards, 22 outcome achievement, and program integrity. The executive 23 committee shall report its findings and recommendations to the 24 medical assistance advisory council for review and comment by 25 October 1, 2018, and shall submit a final report of findings 26 and recommendations to the governor and the general assembly by 27 December 31, 2018. 28 DIVISION V 29 TARGETED CASE MANAGEMENT AND INPATIENT PSYCHIATRIC SERVICES 30 REIMBURSEMENT 31 Sec. 6. Section 249A.31, Code 2018, is amended to read as 32 follows: 33 249A.31 Cost-based reimbursement. 34 1. Providers of individual case management services for 35 -7- HF 2483 (4) 87 pf/rh/md 7/ 8

H.F. 2483 persons with an intellectual disability, a developmental 1 disability, or chronic mental illness shall receive cost-based 2 reimbursement for one hundred percent of the reasonable 3 costs for the provision of the services in accordance with 4 standards adopted by the mental health and disability services 5 commission pursuant to section 225C.6 . Effective July 1, 2018, 6 targeted case management services shall be reimbursed based 7 on a statewide fee schedule amount developed by rule of the 8 department pursuant to chapter 17A. 9 2. Effective July 1, 2010 2014 , the department shall apply 10 a cost-based reimbursement methodology for reimbursement of 11 psychiatric medical institution for children providers of 12 inpatient psychiatric services for individuals under twenty-one 13 years of age shall be reimbursed as follows: 14 a. For non-state-owned providers, services shall be 15 reimbursed according to a fee schedule without reconciliation . 16 b. For state-owned providers, services shall be reimbursed 17 at one hundred percent of the actual and allowable cost of 18 providing the service. 19 -8- HF 2483 (4) 87 pf/rh/md 8/ 8