Senate Amendment 3224
PAG LIN
1 1 Amend House File 580 as follows:
1 2 #1. By striking everything after the enacting
1 3 clause, and inserting the following:
1 4 <Section 1. NEW SECTION. 249J.24A
1 5 NONPARTICIPATING PROVIDER REIMBURSEMENT FOR COVERED
1 6 SERVICES == REIMBURSEMENT FUND.
1 7 1. Beginning July 1, 2010, the department of human
1 8 services shall include in any medical assistance
1 9 program waiver relating to the continuation of the
1 10 IowaCare program pursuant to this chapter, provisions
1 11 for reimbursement of covered expansion population
1 12 services provided to an expansion population member by
1 13 a nonparticipating provider if the nonparticipating
1 14 provider contacts the appropriate participating
1 15 provider prior to providing covered services to verify
1 16 consensus regarding one of the following courses of
1 17 action:
1 18 a. If the nonparticipating provider and the
1 19 participating provider agree that the medical status
1 20 of the expansion population member indicates it is
1 21 medically possible to postpone provision of services,
1 22 the nonparticipating provider shall direct the
1 23 expansion population member to the appropriate
1 24 participating provider for services.
1 25 b. If the nonparticipating provider and the
1 26 participating provider agree that the medical status
1 27 of the expansion population member indicates it is not
1 28 medically possible to postpone provision of services,
1 29 the nonparticipating provider shall provide medically
1 30 necessary services.
1 31 c. If the nonparticipating provider and the
1 32 participating provider agree that transfer of the
1 33 expansion population member is not possible due to
1 34 lack of available inpatient capacity, the
1 35 nonparticipating provider shall provide medically
1 36 necessary services.
1 37 d. If the medical status of the expansion
1 38 population member indicates a medical emergency and
1 39 the nonparticipating provider is not able to contact
1 40 the appropriate participating provider prior to
1 41 providing medically necessary services, the
1 42 nonparticipating provider shall document the medical
1 43 emergency and inform the appropriate participating
1 44 provider immediately after the member has been
1 45 stabilized of any covered services provided.
1 46 2. If the nonparticipating provider meets the
1 47 requirements specified in subsection 1, the
1 48 nonparticipating provider shall be reimbursed for
1 49 covered expansion population services provided to the
1 50 expansion population member through the
2 1 nonparticipating provider reimbursement fund in
2 2 accordance with the following:
2 3 a. The nonparticipating provider shall request
2 4 reimbursement from the department through an exception
2 5 to policy request as provided in departmental rule.
2 6 The nonparticipating provider shall submit a clean
2 7 claim to the department for reimbursement within
2 8 twenty days of provision of the covered service. The
2 9 department shall adopt rules relating to the format of
2 10 and the information to be included in the request for
2 11 reimbursement.
2 12 b. The nonparticipating provider shall include in
2 13 the request for reimbursement only clean claims for
2 14 inpatient hospital services provided to the expansion
2 15 population member during the episode of care or
2 16 treatment described in subsection 1.
2 17 c. Reimbursement shall be based on the
2 18 reimbursement rates and policies applicable to the
2 19 nonparticipating provider under the full benefit
2 20 medical assistance program, subject to the
2 21 availability of funds in the nonparticipating provider
2 22 reimbursement fund and subject to the appropriation of
2 23 moneys in the fund to the department.
2 24 d. The department shall reimburse the
2 25 nonparticipating provider only if the recipient of the
2 26 services is an expansion population member with active
2 27 eligibility status at the time the services are
2 28 provided.
2 29 3. a. A nonparticipating provider reimbursement
2 30 fund is created in the state treasury under the
2 31 authority of the department. Moneys designated for
2 32 deposit in the fund that are received from sources
2 33 including but not limited to appropriations from the
2 34 general fund of the state, grants, and contributions,
2 35 shall be deposited in the fund.
2 36 b. Moneys in the fund shall be separate from the
2 37 general fund of the state and shall not be considered
2 38 part of the general fund of the state. The moneys
2 39 deposited in the fund are not subject to section 8.33
2 40 and shall not be transferred, used, obligated,
2 41 appropriated, or otherwise encumbered, except to
2 42 provide for the purposes specified in this section.
2 43 Notwithstanding section 12C.7, subsection 2, interest
2 44 or earnings on moneys deposited in the fund shall be
2 45 credited to the fund.
2 46 c. Moneys deposited in the fund shall be used only
2 47 to reimburse nonparticipating providers who provide
2 48 covered services to expansion population members if no
2 49 other third party is liable for reimbursement and as
2 50 specified in subsections 1 and 2.
3 1 d. The department shall attempt to maximize
3 2 receipt of federal matching funds under the medical
3 3 assistance program for covered services provided under
3 4 this section if such attempt does not directly or
3 5 indirectly limit the federal funds available to
3 6 participating providers.
3 7 4. For the purposes of this section,
3 8 "nonparticipating provider" means a hospital licensed
3 9 pursuant to chapter 135B that is not a member of the
3 10 expansion population provider network as specified in
3 11 section 249J.7.
3 12 Sec. 2. CONTINGENT IMPLEMENTATION.
3 13 Notwithstanding the requirement of this Act directing
3 14 the department of human services to include provisions
3 15 for reimbursement of covered services provided to an
3 16 expansion population member by a nonparticipating
3 17 provider under any medical assistance program waiver
3 18 relating to the continuation of the IowaCare program,
3 19 if the department of human services in consultation
3 20 with the governor determines that such requirement
3 21 would adversely affect continuation of the IowaCare
3 22 waiver, the department shall not include such
3 23 provisions in the IowaCare waiver and this Act shall
3 24 not be implemented.>
3 25 #2. Title page, by striking line 2 and inserting
3 26 the following: <for covered services provided to
3 27 IowaCare program members, creating a reimbursement
3 28 fund, and providing for contingent implementation.>
3 29
3 30
3 31
3 32 AMANDA RAGAN
3 33 HF 580.502 83
3 34 pf/nh/22993
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