House File 2460 H-8247 Amend House File 2460 as follows: 1 1. Page 41, line 14, by striking < 17,045,964 > and 2 inserting < 19,119,864 > 3 2. Page 43, after line 3 by inserting: 4 < ___. Of the funds appropriated in this section, 5 $2,073,900 shall be used for the purposes of additional 6 Medicaid managed care oversight requirements as 7 otherwise specified in this Act, $360,000 of which 8 shall be transferred to the appropriation in this Act 9 for the office of long-term care ombudsman to be used 10 for the purposes specified in section 231.44. 11 3. Page 85, after line 4 by inserting: 12 < REPORTING OF EXISTING DATA REQUIREMENTS, MINUTES, AND 13 RECOMMENDATIONS > 14 4. Page 92, after line 18 by inserting: 15 < DIVISION ___ 16 MEDICAID MANAGED CARE —— ADDITIONAL OVERSIGHT 17 REQUIREMENTS 18 Sec. ___. LEGISLATIVE FINDINGS —— GOALS AND INTENT. 19 1. The general assembly finds all of the following: 20 a. In the majority of states, Medicaid managed care 21 has been introduced on an incremental basis, beginning 22 with the enrollment of low-income children and parents 23 and proceeding in stages to include nonelderly persons 24 with disabilities and older individuals. Iowa, unlike 25 the majority of states, is implementing Medicaid 26 managed care simultaneously across a broad and diverse 27 population that includes individuals with complex 28 health care and long-term services and supports needs, 29 making these individuals especially vulnerable to 30 receiving inappropriate, inadequate, or substandard 31 services and supports. 32 b. The success or failure of Medicaid managed 33 care in Iowa depends on proper strategic planning and 34 strong oversight, and the incorporation of the core 35 -1- HF2460.3521 (3) 86 pf/rn 1/ 43 #1. #2.
values, principles, and goals of the strategic plan 1 into Medicaid managed care contractual obligations. 2 While Medicaid managed care techniques may create 3 pathways and offer opportunities toward quality 4 improvement and predictability in costs, if cost 5 savings and administrative efficiencies are the 6 primary goals, Medicaid managed care may instead erect 7 new barriers and limit the care and support options 8 available, especially to high-need, vulnerable Medicaid 9 recipients. A well-designed strategic plan and 10 effective oversight ensure that cost savings, improved 11 health outcomes, and efficiencies are not achieved 12 at the expense of diminished program integrity, a 13 reduction in the quality or availability of services, 14 or adverse consequences to the health and well-being of 15 Medicaid recipients. 16 c. Strategic planning should include all of the 17 following: 18 (1) Guidance in establishing and maintaining a 19 robust and appropriate workforce and a provider network 20 capable of addressing all of the diverse, distinct, and 21 wide-ranging treatment and support needs of Medicaid 22 recipients. 23 (2) Developing a sound methodology for establishing 24 and adjusting capitation rates to account for all 25 essential costs involved in treating and supporting the 26 entire spectrum of needs across recipient populations. 27 (3) Addressing the sufficiency of information and 28 data resources to enable review of factors such as 29 utilization, service trends, system performance, and 30 outcomes. 31 (4) Building effective working relationships and 32 developing strategies to support community-level 33 integration that provides cross-system coordination 34 and synchronization among the various service sectors, 35 -2- HF2460.3521 (3) 86 pf/rn 2/ 43
providers, agencies, and organizations to further 1 holistic well-being and population health goals. 2 d. While the contracts entered into between the 3 state and managed care organizations function as a 4 mechanism for enforcing requirements established by the 5 federal and state governments and allow states to shift 6 the financial risk associated with caring for Medicaid 7 recipients to these contractors, the state ultimately 8 retains responsibility for the Medicaid program and 9 the oversight of the performance of the program’s 10 contractors. Administration of the Medicaid program 11 benefits by managed care organizations should not be 12 viewed by state policymakers and state agencies as a 13 means of divesting themselves of their constitutional 14 and statutory responsibilities to ensure that 15 recipients of publicly funded services and supports, as 16 well as taxpayers in general, are effectively served. 17 e. Overseeing the performance of Medicaid managed 18 care contractors requires a different set of skills 19 than those required for administering a fee-for-service 20 program. In the absence of the in-house capacity of 21 the department of human services to perform tasks 22 specific to Medicaid managed care oversight, the state 23 essentially cedes its responsibilities to private 24 contractors and relinquishes its accountability to the 25 public. In order to meet these responsibilities, state 26 policymakers must ensure that the state, including the 27 department of human services as the state Medicaid 28 agency, has the authority and resources, including 29 the adequate number of qualified personnel and the 30 necessary tools, to carry out these responsibilities, 31 provide effective administration, and ensure 32 accountability and compliance. 33 f. State policymakers must also ensure that 34 Medicaid managed care contracts contain, at a minimum, 35 -3- HF2460.3521 (3) 86 pf/rn 3/ 43
clear, unambiguous performance standards, operating 1 guidelines, data collection, maintenance, retention, 2 and reporting requirements, and outcomes expectations 3 so that contractors and subcontractors are held 4 accountable to clear contract specifications. 5 g. As with all system and program redesign efforts 6 undertaken in the state to date, the assumption 7 of the administration of Medicaid program benefits 8 by managed care organizations must involve ongoing 9 stakeholder input and earn the trust and support of 10 these stakeholders. Medicaid recipients, providers, 11 advocates, and other stakeholders have intimate 12 knowledge of the people and processes involved in 13 ensuring the health and safety of Medicaid recipients, 14 and are able to offer valuable insight into the 15 barriers likely to be encountered as well as propose 16 solutions for overcoming these obstacles. Local 17 communities and providers of services and supports 18 have firsthand experience working with the Medicaid 19 recipients they serve and are able to identify factors 20 that must be considered to make a system successful. 21 Agencies and organizations that have specific expertise 22 and experience with the services and supports needs of 23 Medicaid recipients and their families are uniquely 24 placed to provide needed assistance in developing 25 the measures for and in evaluating the quality of the 26 program. 27 2. It is the intent of the general assembly that 28 the Medicaid program be implemented and administered, 29 including through Medicaid managed care policies 30 and contract provisions, in a manner that safeguards 31 the interests of Medicaid recipients, encourages the 32 participation of Medicaid providers, and protects 33 the interests of all taxpayers, while attaining the 34 goals of Medicaid modernization to improve quality and 35 -4- HF2460.3521 (3) 86 pf/rn 4/ 43
access, promote accountability for outcomes, and create 1 a more predictable and sustainable Medicaid budget. 2 HEALTH POLICY OVERSIGHT COMMITTEE 3 Sec. ___. Section 2.45, subsection 6, Code 2016, is 4 amended to read as follows: 5 6. The legislative health policy oversight 6 committee, which shall be composed of ten members of 7 the general assembly, consisting of five members from 8 each house, to be appointed by the legislative council. 9 The legislative health policy oversight committee 10 shall receive updates and review data, public input and 11 concerns, and make recommendations for improvements to 12 and changes in law or rule regarding Medicaid managed 13 care meet at least four times annually to evaluate 14 state health policy and provide continuing oversight 15 for publicly funded programs, including but not limited 16 to all facets of the Medicaid and hawk-i programs 17 to, at a minimum, ensure effective and efficient 18 administration of these programs, address stakeholder 19 concerns, monitor program costs and expenditures, and 20 make recommendations relative to the programs . 21 Sec. ___. HEALTH POLICY OVERSIGHT COMMITTEE 22 —— SUBJECT MATTER REVIEW FOR 2016 LEGISLATIVE 23 INTERIM. During the 2016 legislative interim, the 24 health policy oversight committee created in section 25 2.45 shall, as part of the committee’s evaluation 26 of state health policy and review of all facets of 27 the Medicaid and hawk-i programs, review and make 28 recommendations regarding, at a minimum, all of the 29 following: 30 1. The resources and duties of the office of 31 long-term care ombudsman relating to the provision of 32 assistance to and advocacy for Medicaid recipients 33 to determine the designation of duties and level of 34 resources necessary to appropriately address the needs 35 -5- HF2460.3521 (3) 86 pf/rn 5/ 43
of such individuals. The committee shall consider the 1 health consumer ombudsman alliance report submitted to 2 the general assembly in December 2015, as well as input 3 from the office of long-term care ombudsman and other 4 entities in making recommendations. 5 2. The health benefits and health benefit 6 utilization management criteria for the Medicaid 7 and hawk-i programs to determine the sufficiency 8 and appropriateness of the benefits offered and the 9 utilization of these benefits. 10 3. Prior authorization requirements relative 11 to benefits provided under the Medicaid and hawk-i 12 programs, including but not limited to pharmacy 13 benefits. 14 4. Consistency and uniformity in processes, 15 procedures, forms, and other activities across all 16 Medicaid and hawk-i program participating insurers and 17 managed care organizations, including but not limited 18 to cost and quality reporting, credentialing, billing, 19 prior authorization, and critical incident reporting. 20 5. Provider network adequacy including the use of 21 out-of-network and out-of-state providers. 22 6. The role and interplay of other advisory and 23 oversight entities, including but not limited to the 24 medical assistance advisory council and the hawk-i 25 board. 26 REVIEW OF PROGRAM INTEGRITY DUTIES 27 Sec. ___. REVIEW OF PROGRAM INTEGRITY DUTIES —— 28 WORKGROUP —— REPORT. 29 1. The director of human services shall convene 30 a workgroup comprised of members including the 31 commissioner of insurance, the auditor of state, the 32 Medicaid director and bureau chiefs of the managed care 33 organization oversight and supports bureau, the Iowa 34 Medicaid enterprise support bureau, and the medical 35 -6- HF2460.3521 (3) 86 pf/rn 6/ 43
and long-term services and supports bureau, and a 1 representative of the program integrity unit, or their 2 designees; and representatives of other appropriate 3 state agencies or other entities including but not 4 limited to the office of the attorney general, the 5 office of long-term care ombudsman, and the Medicaid 6 fraud control unit of the investigations division 7 of the department of inspections and appeals. The 8 workgroup shall do all of the following: 9 a. Review the duties of each entity with 10 responsibilities relative to Medicaid program integrity 11 and managed care organizations; review state and 12 federal laws, regulations, requirements, guidance, and 13 policies relating to Medicaid program integrity and 14 managed care organizations; and review the laws of 15 other states relating to Medicaid program integrity 16 and managed care organizations. The workgroup shall 17 determine areas of duplication, fragmentation, 18 and gaps; shall identify possible integration, 19 collaboration and coordination of duties; and shall 20 determine whether existing general state Medicaid 21 program and fee-for-service policies, laws, and 22 rules are sufficient, or if changes or more specific 23 policies, laws, and rules are required to provide 24 for comprehensive and effective administration and 25 oversight of the Medicaid program including under the 26 fee-for-service and managed care methodologies. 27 b. Review historical uses of the Medicaid 28 fraud fund created in section 249A.50 and make 29 recommendations for future uses of the moneys in the 30 fund and any changes in law necessary to adequately 31 address program integrity. 32 c. Review medical loss ratio provisions relative 33 to Medicaid managed care contracts and make 34 recommendations regarding, at a minimum, requirements 35 -7- HF2460.3521 (3) 86 pf/rn 7/ 43
for the necessary collection, maintenance, retention, 1 reporting, and sharing of data and information by 2 Medicaid managed care organizations for effective 3 determination of compliance, and to identify the 4 costs and activities that should be included in the 5 calculation of administrative costs, medical costs or 6 benefit expenses, health quality improvement costs, 7 and other costs and activities incidental to the 8 determination of a medical loss ratio. 9 d. Review the capacity of state agencies, including 10 the need for specialized training and expertise, to 11 address Medicaid and managed care organization program 12 integrity and provide recommendations for the provision 13 of necessary resources and infrastructure, including 14 annual budget projections. 15 e. Review the incentives and penalties applicable 16 to violations of program integrity requirements to 17 determine their adequacy in combating waste, fraud, 18 abuse, and other violations that divert limited 19 resources that would otherwise be expended to safeguard 20 the health and welfare of Medicaid recipients, and make 21 recommendations for necessary adjustments to improve 22 compliance. 23 f. Make recommendations regarding the quarterly and 24 annual auditing of financial reports required to be 25 performed for each Medicaid managed care organization 26 to ensure that the activities audited provide 27 sufficient information to the division of insurance 28 of the department of commerce and the department 29 of human services to ensure program integrity. The 30 recommendations shall also address the need for 31 additional audits or other reviews of managed care 32 organizations. 33 g. Review and make recommendations to prohibit 34 cost-shifting between state and local and public and 35 -8- HF2460.3521 (3) 86 pf/rn 8/ 43
private funding sources for services and supports 1 provided to Medicaid recipients whether directly or 2 indirectly through the Medicaid program. 3 2. The department of human services shall submit 4 a report of the workgroup to the governor, the health 5 policy oversight committee created in section 2.45, 6 and the general assembly initially, on or before 7 November 15, 2016, and on or before November 15, 8 on an annual basis thereafter, to provide findings 9 and recommendations for a coordinated approach 10 to comprehensive and effective administration and 11 oversight of the Medicaid program including under the 12 fee-for-service and managed care methodologies. 13 MEDICAID OMBUDSMAN 14 Sec. ___. Section 231.44, Code 2016, is amended to 15 read as follows: 16 231.44 Utilization of resources —— assistance and 17 advocacy related to long-term services and supports 18 under the Medicaid program. 19 1. The office of long-term care ombudsman may 20 shall utilize its available resources to provide 21 assistance and advocacy services to eligible recipients 22 of long-term services and supports , or individuals 23 seeking long-term services and supports, and the 24 families or legal representatives of such eligible 25 recipients, of long-term services and supports provided 26 through individuals under the Medicaid program. Such 27 assistance and advocacy shall include but is not 28 limited to all of the following: 29 a. Assisting recipients such individuals in 30 understanding the services, coverage, and access 31 provisions and their rights under Medicaid managed 32 care. 33 b. Developing procedures for the tracking and 34 reporting of the outcomes of individual requests for 35 -9- HF2460.3521 (3) 86 pf/rn 9/ 43
assistance, the obtaining of necessary services and 1 supports, and other aspects of the services provided to 2 eligible recipients such individuals . 3 c. Providing advice and assistance relating to the 4 preparation and filing of complaints, grievances, and 5 appeals of complaints or grievances, including through 6 processes available under managed care plans and the 7 state appeals process, relating to long-term services 8 and supports under the Medicaid program. 9 d. Accessing the results of a review of a level 10 of care assessment or reassessment by a managed care 11 organization in which the managed care organization 12 recommends denial or limited authorization of a 13 service, including the type or level of service, the 14 reduction, suspension, or termination of a previously 15 authorized service, or a change in level of care, upon 16 the request of an affected individual. 17 e. Receiving notices of disenrollment or notices 18 that would result in a change in level of care for 19 affected individuals, including involuntary and 20 voluntary discharges or transfers, from the department 21 of human services or a managed care organization. 22 2. A representative of the office of long-term care 23 ombudsman providing assistance and advocacy services 24 authorized under this section for an individual, 25 shall be provided access to the individual, and shall 26 be provided access to the individual’s medical and 27 social records as authorized by the individual or the 28 individual’s legal representative, as necessary to 29 carry out the duties specified in this section . 30 3. A representative of the office of long-term care 31 ombudsman providing assistance and advocacy services 32 authorized under this section for an individual, shall 33 be provided access to administrative records related to 34 the provision of the long-term services and supports to 35 -10- HF2460.3521 (3) 86 pf/rn 10/ 43
the individual, as necessary to carry out the duties 1 specified in this section . 2 4. The office of long-term care ombudsman and 3 representatives of the office, when providing 4 assistance and advocacy services under this section, 5 shall be considered a health oversight agency as 6 defined in 45 C.F.R. §164.501 for the purposes of 7 health oversight activities as described in 45 C.F.R. 8 §164.512(d) including access to the health records 9 and other appropriate information of an individual, 10 including from the department of human services or 11 the applicable Medicaid managed care organization, 12 as necessary to fulfill the duties specified under 13 this section. The department of human services, 14 in collaboration with the office of long-term care 15 ombudsman, shall adopt rules to ensure compliance 16 by affected entities with this subsection and to 17 ensure recognition of the office of long-term care 18 ombudsman as a duly authorized and identified agent or 19 representative of the state. 20 5. The department of human services and Medicaid 21 managed care organizations shall inform eligible 22 and potentially eligible Medicaid recipients of the 23 advocacy services and assistance available through the 24 office of long-term care ombudsman and shall provide 25 contact and other information regarding the advocacy 26 services and assistance to eligible and potentially 27 eligible Medicaid recipients as directed by the office 28 of long-term care ombudsman. 29 6. When providing assistance and advocacy services 30 under this section, the office of long-term care 31 ombudsman shall act as an independent agency, and the 32 office of long-term care ombudsman and representatives 33 of the office shall be free of any undue influence that 34 restrains the ability of the office or the office’s 35 -11- HF2460.3521 (3) 86 pf/rn 11/ 43
representatives from providing such services and 1 assistance. 2 7. The office of long-term care ombudsman shall, in 3 addition to other duties prescribed and at a minimum, 4 do all of the following in the furtherance of the 5 provision of advocacy services and assistance under 6 this section: 7 a. Represent the interests of eligible and 8 potentially eligible Medicaid recipients before 9 governmental agencies. 10 b. Analyze, comment on, and monitor the development 11 and implementation of federal, state, and local laws, 12 regulations, and other governmental policies and 13 actions, and recommend any changes in such laws, 14 regulations, policies, and actions as determined 15 appropriate by the office of long-term care ombudsman. 16 c. To maintain transparency and accountability for 17 activities performed under this section, including 18 for the purposes of claiming federal financial 19 participation for activities that are performed to 20 assist with administration of the Medicaid program: 21 (1) Have complete and direct responsibility for the 22 administration, operation, funding, fiscal management, 23 and budget related to such activities, and directly 24 employ, oversee, and supervise all paid and volunteer 25 staff associated with these activities. 26 (2) Establish separation-of-duties requirements, 27 provide limited access to work space and work 28 product for only necessary staff, and limit access to 29 documents and information as necessary to maintain the 30 confidentiality of the protected health information of 31 individuals served under this section. 32 (3) Collect and submit, annually, to the governor, 33 the health policy oversight committee created in 34 section 2.45, and the general assembly, all of the 35 -12- HF2460.3521 (3) 86 pf/rn 12/ 43
following with regard to those seeking advocacy 1 services or assistance under this section: 2 (a) The number of contacts by contact type and 3 geographic location. 4 (b) The type of assistance requested including the 5 name of the managed care organization involved, if 6 applicable. 7 (c) The time frame between the time of the initial 8 contact and when an initial response was provided. 9 (d) The amount of time from the initial contact to 10 resolution of the problem or concern. 11 (e) The actions taken in response to the request 12 for advocacy or assistance. 13 (f) The outcomes of requests to address problems or 14 concerns. 15 4. 8. For the purposes of this section : 16 a. “Institutional setting” includes a long-term care 17 facility, an elder group home, or an assisted living 18 program. 19 b. “Long-term services and supports” means the broad 20 range of health, health-related, and personal care 21 assistance services and supports, provided in both 22 institutional settings and home and community-based 23 settings, necessary for older individuals and persons 24 with disabilities who experience limitations in their 25 capacity for self-care due to a physical, cognitive, or 26 mental disability or condition. 27 Sec. ___. NEW SECTION . 231.44A Willful 28 interference with duties related to long-term services 29 and supports —— penalty. 30 Willful interference with a representative of the 31 office of long-term care ombudsman in the performance 32 of official duties in accordance with section 231.44 33 is a violation of section 231.44, subject to a penalty 34 prescribed by rule. The office of long-term care 35 -13- HF2460.3521 (3) 86 pf/rn 13/ 43
ombudsman shall adopt rules specifying the amount of a 1 penalty imposed, consistent with the penalties imposed 2 under section 231.42, subsection 8, and specifying 3 procedures for notice and appeal of penalties imposed. 4 MEDICAL ASSISTANCE ADVISORY COUNCIL 5 Sec. ___. Section 249A.4B, Code 2016, is amended to 6 read as follows: 7 249A.4B Medical assistance advisory council. 8 1. A medical assistance advisory council is 9 created to comply with 42 C.F.R. §431.12 based on 10 section 1902(a)(4) of the federal Social Security Act 11 and to advise the director about health and medical 12 care services under the medical assistance Medicaid 13 program , participate in Medicaid policy development 14 and program administration, and provide guidance on 15 key issues related to the Medicaid program, whether 16 administered under a fee-for-service, managed care, or 17 other methodology, including but not limited to access 18 to care, quality of care, and service delivery . 19 a. The council shall have the opportunity for 20 participation in policy development and program 21 administration, including furthering the participation 22 of recipients of the program, and without limiting this 23 general authority shall specifically do all of the 24 following: 25 (1) Formulate, review, evaluate, and recommend 26 policies, rules, agency initiatives, and legislation 27 pertaining to the Medicaid program. The council shall 28 have the opportunity to comment on proposed rules 29 prior to commencement of the rulemaking process and on 30 waivers and state plan amendment applications. 31 (2) Prior to the annual budget development process, 32 engage in setting priorities, including consideration 33 of the scope and utilization management criteria 34 for benefits, beneficiary eligibility, provider and 35 -14- HF2460.3521 (3) 86 pf/rn 14/ 43
services reimbursement rates, and other budgetary 1 issues. 2 (3) Provide oversight for and review of the 3 administration of the Medicaid program. 4 (4) Ensure that the membership of the council 5 effectively represents all relevant and concerned 6 viewpoints, particularly those of consumers, providers, 7 and the general public; create public understanding; 8 and ensure that the services provided under the 9 Medicaid program meet the needs of the people served. 10 b. The council shall meet no more than at least 11 quarterly , and prior to the next subsequent meeting 12 of the executive committee . The director of public 13 health The public member acting as a co-chairperson 14 of the executive committee and the professional or 15 business entity member acting as a co-chairperson of 16 the executive committee, shall serve as chairperson 17 co-chairpersons of the council. 18 2. The council shall include all of the following 19 voting members: 20 a. The president, or the president’s 21 representative, of each of the following professional 22 or business entities, or a member of each of the 23 following professional or business entities, selected 24 by the entity: 25 (1) The Iowa medical society. 26 (2) The Iowa osteopathic medical association. 27 (3) The Iowa academy of family physicians. 28 (4) The Iowa chapter of the American academy of 29 pediatrics. 30 (5) The Iowa physical therapy association. 31 (6) The Iowa dental association. 32 (7) The Iowa nurses association. 33 (8) The Iowa pharmacy association. 34 (9) The Iowa podiatric medical society. 35 -15- HF2460.3521 (3) 86 pf/rn 15/ 43
(10) The Iowa optometric association. 1 (11) The Iowa association of community providers. 2 (12) The Iowa psychological association. 3 (13) The Iowa psychiatric society. 4 (14) The Iowa chapter of the national association 5 of social workers. 6 (15) The coalition for family and children’s 7 services in Iowa. 8 (16) The Iowa hospital association. 9 (17) The Iowa association of rural health clinics. 10 (18) The Iowa primary care association. 11 (19) Free clinics of Iowa. 12 (20) The opticians’ association of Iowa, inc. 13 (21) The Iowa association of hearing health 14 professionals. 15 (22) The Iowa speech and hearing association. 16 (23) The Iowa health care association. 17 (24) The Iowa association of area agencies on 18 aging. 19 (25) AARP. 20 (26) The Iowa caregivers association. 21 (27) The Iowa coalition of home and community-based 22 services for seniors. 23 (28) The Iowa adult day services association. 24 (29) Leading age Iowa. 25 (30) The Iowa association for home care. 26 (31) The Iowa council of health care centers. 27 (32) The Iowa physician assistant society. 28 (33) The Iowa association of nurse practitioners. 29 (34) The Iowa nurse practitioner society. 30 (35) The Iowa occupational therapy association. 31 (36) The ARC of Iowa, formerly known as the 32 association for retarded citizens of Iowa. 33 (37) The national alliance for the mentally ill on 34 mental illness of Iowa. 35 -16- HF2460.3521 (3) 86 pf/rn 16/ 43
(38) The Iowa state association of counties. 1 (39) The Iowa developmental disabilities council. 2 (40) The Iowa chiropractic society. 3 (41) The Iowa academy of nutrition and dietetics. 4 (42) The Iowa behavioral health association. 5 (43) The midwest association for medical equipment 6 services or an affiliated Iowa organization. 7 (44) The Iowa public health association. 8 (45) The epilepsy foundation. 9 b. Public representatives which may include members 10 of consumer groups, including recipients of medical 11 assistance or their families, consumer organizations, 12 and others, which shall be appointed by the governor 13 in equal in number to the number of representatives of 14 the professional and business entities specifically 15 represented under paragraph “a” , appointed by the 16 governor for staggered terms of two years each, none 17 of whom shall be members of, or practitioners of, or 18 have a pecuniary interest in any of the professional 19 or business entities specifically represented under 20 paragraph “a” , and a majority of whom shall be current 21 or former recipients of medical assistance or members 22 of the families of current or former recipients. 23 3. The council shall include all of the following 24 nonvoting members: 25 c. a. The director of public health, or the 26 director’s designee. 27 d. b. The director of the department on aging, or 28 the director’s designee. 29 c. The state long-term care ombudsman, or the 30 ombudsman’s designee. 31 d. The ombudsman appointed pursuant to section 32 2C.3, or the ombudsman’s designee. 33 e. The dean of Des Moines university —— osteopathic 34 medical center, or the dean’s designee. 35 -17- HF2460.3521 (3) 86 pf/rn 17/ 43
f. The dean of the university of Iowa college of 1 medicine, or the dean’s designee. 2 g. The following members of the general assembly, 3 each for a term of two years as provided in section 4 69.16B : 5 (1) Two members of the house of representatives, 6 one appointed by the speaker of the house of 7 representatives and one appointed by the minority 8 leader of the house of representatives from their 9 respective parties. 10 (2) Two members of the senate, one appointed by the 11 president of the senate after consultation with the 12 majority leader of the senate and one appointed by the 13 minority leader of the senate. 14 3. 4. a. An executive committee of the council is 15 created and shall consist of the following members of 16 the council: 17 (1) As voting members: 18 (a) Five of the professional or business entity 19 members designated pursuant to subsection 2 , paragraph 20 “a” , and selected by the members specified under that 21 paragraph. 22 (2) (b) Five of the public members appointed 23 pursuant to subsection 2 , paragraph “b” , and selected 24 by the members specified under that paragraph. Of the 25 five public members, at least one member shall be a 26 recipient of medical assistance. 27 (3) (2) As nonvoting members: 28 (a) The director of public health, or the 29 director’s designee. 30 (b) The director of the department on aging, or the 31 director’s designee. 32 (c) The state long-term care ombudsman, or the 33 ombudsman’s designee. 34 (d) The ombudsman appointed pursuant to section 35 -18- HF2460.3521 (3) 86 pf/rn 18/ 43
2C.3, or the ombudsman’s designee. 1 b. The executive committee shall meet on a monthly 2 basis. The director of public health A public member 3 of the executive committee selected by the public 4 members appointed pursuant to subsection 2, paragraph 5 “b” , and a professional or business entity member of 6 the executive committee selected by the professional 7 or business entity members appointed pursuant to 8 subsection 2, paragraph “a” , shall serve as chairperson 9 co-chairpersons of the executive committee. 10 c. Based upon the deliberations of the council , 11 and the executive committee, and the subcommittees, 12 the executive committee , the council, and the 13 subcommittees, respectively, shall make recommendations 14 to the director , to the health policy oversight 15 committee created in section 2.45, to the general 16 assembly’s joint appropriations subcommittee on health 17 and human services, and to the general assembly’s 18 standing committees on human resources regarding the 19 budget, policy, and administration of the medical 20 assistance program. 21 5. a. The council shall create the following 22 subcommittees, and may create additional subcommittees 23 as necessary to address Medicaid program policies, 24 administration, budget, and other factors and issues: 25 (1) A stakeholder safeguards subcommittee, for 26 which the co-chairpersons shall be a public member 27 of the council appointed pursuant to subsection 2, 28 paragraph “b” , and selected by the public members of 29 the council, and a representative of a professional 30 or business entity appointed pursuant to subsection 31 2, paragraph “a” , and selected by the professional or 32 business entity representatives of the council. The 33 mission of the stakeholder safeguards subcommittee 34 is to provide for ongoing stakeholder engagement and 35 -19- HF2460.3521 (3) 86 pf/rn 19/ 43
feedback on issues affecting Medicaid recipients, 1 providers, and other stakeholders, including but not 2 limited to benefits such as transportation, benefit 3 utilization management, the inclusion of out-of-state 4 and out-of-network providers and the use of single-case 5 agreements, and reimbursement of providers and 6 services. 7 (2) The long-term services and supports 8 subcommittee which shall be chaired by the state 9 long-term care ombudsman, or the ombudsman’s designee. 10 The mission of the long-term services and supports 11 subcommittee is to be a resource and to provide advice 12 on policy development and program administration 13 relating to Medicaid long-term services and supports 14 including but not limited to developing outcomes and 15 performance measures for Medicaid managed care for the 16 long-term services and supports population; addressing 17 issues related to home and community-based services 18 waivers and waiting lists; and reviewing the system of 19 long-term services and supports to ensure provision of 20 home and community-based services and the rebalancing 21 of the health care infrastructure in accordance with 22 state and federal law including but not limited to the 23 principles established in Olmstead v. L.C., 527 U.S. 24 581 (1999) and the federal Americans with Disabilities 25 Act and in a manner that reflects a sustainable, 26 person-centered approach to improve health and life 27 outcomes, supports maximum independence, addresses 28 medical and social needs in a coordinated, integrated 29 manner, and provides for sufficient resources including 30 a stable, well-qualified workforce. The subcommittee 31 shall also address and make recommendations regarding 32 the need for an ombudsman function for eligible and 33 potentially eligible Medicaid recipients beyond the 34 long-term services and supports population. 35 -20- HF2460.3521 (3) 86 pf/rn 20/ 43
(3) The transparency, data, and program evaluation 1 subcommittee which shall be chaired by the director of 2 the university of Iowa public policy center, or the 3 director’s designee. The mission of the transparency, 4 data, and program evaluation subcommittee is to 5 ensure Medicaid program transparency; ensure the 6 collection, maintenance, retention, reporting, and 7 analysis of sufficient and meaningful data to provide 8 transparency and inform policy development and program 9 effectiveness; support development and administration 10 of a consumer-friendly dashboard; and promote the 11 ongoing evaluation of Medicaid stakeholder satisfaction 12 with the Medicaid program. 13 (4) The program integrity subcommittee which shall 14 be chaired by the Medicaid director, or the director’s 15 designee. The mission of the program integrity 16 subcommittee is to ensure that a comprehensive system 17 including specific policies, laws, and rules and 18 adequate resources and measures are in place to 19 effectively administer the program and to maintain 20 compliance with federal and state program integrity 21 requirements. 22 (5) A health workforce subcommittee, co-chaired 23 by the bureau chief of the bureau of oral and health 24 delivery systems of the department of public health, 25 or the bureau chief’s designee, and the director of 26 the national alliance on mental illness of Iowa, or 27 the director’s designee. The mission of the health 28 workforce subcommittee is to assess the sufficiency 29 and proficiency of the current and projected health 30 workforce; identify barriers to and gaps in health 31 workforce development initiatives and health 32 workforce data to provide foundational, evidence-based 33 information to inform policymaking and resource 34 allocation; evaluate the most efficient application 35 -21- HF2460.3521 (3) 86 pf/rn 21/ 43
and utilization of roles, functions, responsibilities, 1 activities, and decision-making capacity of health 2 care professionals and other allied and support 3 personnel; and make recommendations for improvement 4 in, and alternative modes of, health care delivery in 5 order to provide a competent, diverse, and sustainable 6 health workforce in the state. The subcommittee shall 7 work in collaboration with the office of statewide 8 clinical education programs of the university of Iowa 9 Carver college of medicine, Des Moines university, 10 Iowa workforce development, and other entities with 11 interest or expertise in the health workforce in 12 carrying out the subcommittee’s duties and developing 13 recommendations. 14 b. The co-chairpersons of the council shall 15 appoint members to each subcommittee from the general 16 membership of the council. Consideration in appointing 17 subcommittee members shall include the individual’s 18 knowledge about, and interest or expertise in, matters 19 that come before the subcommittee. 20 c. Subcommittees shall meet at the call of the 21 co-chairpersons or chairperson of the subcommittee, 22 or at the request of a majority of the members of the 23 subcommittee. 24 4. 6. For each council meeting, executive 25 committee meeting, or subcommittee meeting, a quorum 26 shall consist of fifty percent of the membership 27 qualified to vote. Where a quorum is present, a 28 position is carried by a majority of the members 29 qualified to vote. 30 7. For each council meeting, other than those 31 held during the time the general assembly is in 32 session, each legislative member of the council shall 33 be reimbursed for actual travel and other necessary 34 expenses and shall receive a per diem as specified in 35 -22- HF2460.3521 (3) 86 pf/rn 22/ 43
section 7E.6 for each day in attendance, as shall the 1 members of the council , or the executive committee , 2 or a subcommittee, for each day in attendance at a 3 council, executive committee, or subcommittee meeting, 4 who are recipients or the family members of recipients 5 of medical assistance, regardless of whether the 6 general assembly is in session. 7 5. 8. The department shall provide staff support 8 and independent technical assistance to the council , 9 and the executive committee , and the subcommittees . 10 6. 9. The director shall consider comply with 11 the requirements of this section regarding the 12 duties of the council, and the deliberations and 13 recommendations offered by of the council , and the 14 executive committee , and the subcommittees shall be 15 reflected in the director’s preparation of medical 16 assistance budget recommendations to the council 17 on human services pursuant to section 217.3 , and in 18 implementation of medical assistance program policies , 19 and in administration of the Medicaid program . 20 10. The council, executive committee, and 21 subcommittees shall jointly submit quarterly reports 22 to the health policy oversight committee created in 23 section 2.45 and shall jointly submit a report to the 24 governor and the general assembly initially by January 25 1, 2017, and annually, therefore, summarizing the 26 outcomes and findings of their respective deliberations 27 and any recommendations including but not limited to 28 those for changes in law or policy. 29 11. The council, executive committee, and 30 subcommittees may enlist the services of persons who 31 are qualified by education, expertise, or experience 32 to advise, consult with, or otherwise assist the 33 council, executive committee, or subcommittees in the 34 performance of their duties. The council, executive 35 -23- HF2460.3521 (3) 86 pf/rn 23/ 43
committee, or subcommittees may specifically enlist 1 the assistance of entities such as the university of 2 Iowa public policy center to provide ongoing evaluation 3 of the Medicaid program and to make evidence-based 4 recommendations to improve the program. The council, 5 executive committee, and subcommittees shall enlist 6 input from the patient-centered health advisory council 7 created in section 135.159, the mental health and 8 disabilities services commission created in section 9 225C.5, the commission on aging created in section 10 231.11, the bureau of substance abuse of the department 11 of public health, the Iowa developmental disabilities 12 council, and other appropriate state and local entities 13 to provide advice to the council, executive committee, 14 and subcommittees. 15 12. The department, in accordance with 42 C.F.R. 16 §431.12, shall seek federal financial participation for 17 the activities of the council, the executive committee, 18 and the subcommittees. 19 PATIENT-CENTERED HEALTH RESOURCES AND INFRASTRUCTURE 20 Sec. ___. Section 135.159, subsection 2, Code 2016, 21 is amended to read as follows: 22 2. a. The department shall establish a 23 patient-centered health advisory council which shall 24 include but is not limited to all of the following 25 members, selected by their respective organizations, 26 and any other members the department determines 27 necessary to assist in the department’s duties at 28 various stages of development of the medical home 29 system and in the transformation to a patient-centered 30 infrastructure that integrates and coordinates services 31 and supports to address social determinants of health 32 and meet population health goals : 33 (1) The director of human services, or the 34 director’s designee. 35 -24- HF2460.3521 (3) 86 pf/rn 24/ 43
(2) The commissioner of insurance, or the 1 commissioner’s designee. 2 (3) A representative of the federation of Iowa 3 insurers. 4 (4) A representative of the Iowa dental 5 association. 6 (5) A representative of the Iowa nurses 7 association. 8 (6) A physician and an osteopathic physician 9 licensed pursuant to chapter 148 who are family 10 physicians and members of the Iowa academy of family 11 physicians. 12 (7) A health care consumer. 13 (8) A representative of the Iowa collaborative 14 safety net provider network established pursuant to 15 section 135.153 . 16 (9) A representative of the Iowa developmental 17 disabilities council. 18 (10) A representative of the Iowa chapter of the 19 American academy of pediatrics. 20 (11) A representative of the child and family 21 policy center. 22 (12) A representative of the Iowa pharmacy 23 association. 24 (13) A representative of the Iowa chiropractic 25 society. 26 (14) A representative of the university of Iowa 27 college of public health. 28 (15) A representative of the Iowa public health 29 association. 30 (16) A representative of the area agencies on 31 aging. 32 (17) A representative of the mental health and 33 disability services regions. 34 (18) A representative of early childhood Iowa. 35 -25- HF2460.3521 (3) 86 pf/rn 25/ 43
b. Public members of the patient-centered health 1 advisory council shall receive reimbursement for 2 actual expenses incurred while serving in their 3 official capacity only if they are not eligible for 4 reimbursement by the organization that they represent. 5 c. (1) Beginning July 1, 2016, the 6 patient-centered health advisory council shall 7 do all of the following: 8 (a) Review and make recommendations to the 9 department and to the general assembly regarding 10 the building of effective working relationships and 11 strategies to support state-level and community-level 12 integration, to provide cross-system coordination 13 and synchronization, and to more appropriately align 14 health delivery models and service sectors, including 15 but not limited to public health, aging and disability 16 services agencies, mental health and disability 17 services regions, social services, child welfare, and 18 other providers, agencies, organizations, and sectors 19 to address social determinants of health, holistic 20 well-being, and population health goals. Such review 21 and recommendations shall include a review of funding 22 streams and recommendations for blending and braiding 23 funding to support these efforts. 24 (b) Assist in efforts to evaluate the health 25 workforce to inform policymaking and resource 26 allocation. 27 (2) The patient-centered health advisory council 28 shall submit a report to the department, the health 29 policy oversight committee created in section 2.45, and 30 the general assembly, initially, on or before December 31 15, 2016, and on or before December 15, annually, 32 thereafter, including any findings or recommendations 33 resulting from the council’s deliberations. 34 HAWK-I PROGRAM 35 -26- HF2460.3521 (3) 86 pf/rn 26/ 43
Sec. ___. Section 514I.5, subsection 8, paragraph 1 d, Code 2016, is amended by adding the following new 2 subparagraph: 3 NEW SUBPARAGRAPH . (17) Occupational therapy. 4 Sec. ___. Section 514I.5, subsection 8, Code 2016, 5 is amended by adding the following new paragraph: 6 NEW PARAGRAPH . m. The definition of medically 7 necessary and the utilization management criteria under 8 the hawk-i program in order to ensure that benefits 9 are uniformly and consistently provided across all 10 participating insurers in the type and manner that 11 reflects and appropriately meets the needs, including 12 but not limited to the habilitative and rehabilitative 13 needs, of the child population including those children 14 with special health care needs. 15 MEDICAID PROGRAM POLICY IMPROVEMENT 16 Sec. ___. DIRECTIVES FOR MEDICAID PROGRAM POLICY 17 IMPROVEMENTS. In order to safeguard the interests 18 of Medicaid recipients, encourage the participation 19 of Medicaid providers, and protect the interests 20 of all taxpayers, the department of human services 21 shall comply with or ensure that the specified entity 22 complies with all of the following and shall amend 23 Medicaid managed care contract provisions as necessary 24 to reflect all of the following: 25 1. CONSUMER PROTECTIONS. 26 a. In accordance with 42 C.F.R. §438.420, a 27 Medicaid managed care organization shall continue a 28 recipient’s benefits during an appeal process. If, as 29 allowed when final resolution of an appeal is adverse 30 to the Medicaid recipient, the Medicaid managed care 31 organization chooses to recover the costs of the 32 services furnished to the recipient while an appeal is 33 pending, the Medicaid managed care organization shall 34 provide adequate prior notice of potential recovery 35 -27- HF2460.3521 (3) 86 pf/rn 27/ 43
of costs to the recipient at the time the appeal is 1 filed, and any costs recovered shall be remitted to the 2 department of human services. 3 b. Ensure that each Medicaid managed care 4 organization provides, at a minimum, all the benefits 5 and services deemed medically necessary that were 6 covered, including to the extent and in the same manner 7 and subject to the same prior authorization criteria, 8 by the state program directly under fee for service 9 prior to January 1, 2016. Benefits covered through 10 Medicaid managed care shall comply with the specific 11 requirements in state law applicable to the respective 12 Medicaid recipient population under fee for service. 13 c. Enhance monitoring of the reduction in or 14 suspension or termination of services provided to 15 Medicaid recipients, including reductions in the 16 provision of home and community-based services waiver 17 services or increases in home and community-based 18 services waiver waiting lists. Medicaid managed care 19 organizations shall provide data to the department 20 as necessary for the department to compile periodic 21 reports on the numbers of individuals transferred from 22 state institutions and long-term care facilities to 23 home and community-based services, and the associated 24 savings. Any savings resulting from the transfers as 25 certified by the department shall be remitted to the 26 department of human services. 27 d. (1) Require each Medicaid managed care 28 organization to adhere to reasonableness and service 29 authorization standards that are appropriate for and 30 do not disadvantage those individuals who have ongoing 31 chronic conditions or who require long-term services 32 and supports. Services and supports for individuals 33 with ongoing chronic conditions or who require 34 long-term services and supports shall be authorized in 35 -28- HF2460.3521 (3) 86 pf/rn 28/ 43
a manner that reflects the recipient’s continuing need 1 for such services and supports, and limits shall be 2 consistent with a recipient’s current needs assessment 3 and person-centered service plan. 4 (2) In addition to other provisions relating to 5 community-based case management continuity of care 6 requirements, Medicaid managed care contractors shall 7 provide the option to the case manager of a Medicaid 8 recipient who retained the case manager during the 9 six months of transition to Medicaid managed care, if 10 the recipient chooses to continue to retain that case 11 manager beyond the six-month transition period and 12 if the case manager is not otherwise a participating 13 provider of the recipient’s managed care organization 14 provider network, to enter into a single case agreement 15 to continue to provide case management services to the 16 Medicaid recipient. 17 e. Ensure that Medicaid recipients are provided 18 care coordination and case management by appropriately 19 trained professionals in a conflict-free manner. Care 20 coordination and case management shall be provided 21 in a patient-centered and family-centered manner 22 that requires a knowledge of community supports, a 23 reasonable ratio of care coordinators and case managers 24 to Medicaid recipients, standards for frequency of 25 contact with the Medicaid recipient, and specific and 26 adequate reimbursement. 27 f. A Medicaid managed care contract shall include 28 a provision for continuity and coordination of care 29 for a consumer transitioning to Medicaid managed care, 30 including maintaining existing provider-recipient 31 relationships and honoring the amount, duration, and 32 scope of a recipient’s authorized services based on 33 the recipient’s medical history and needs. In the 34 initial transition to Medicaid managed care, to ensure 35 -29- HF2460.3521 (3) 86 pf/rn 29/ 43
the least amount of disruption, Medicaid managed 1 care organizations shall provide, at a minimum, a 2 one-year transition of care period for all provider 3 types, regardless of network status with an individual 4 Medicaid managed care organization. 5 g. Ensure that a Medicaid managed care organization 6 does not arbitrarily deny coverage for medically 7 necessary services based solely on financial reasons 8 and does not shift the responsibility for provision of 9 services or payment of costs of services to another 10 entity to avoid costs or attain savings. 11 h. Ensure that dental coverage, if not integrated 12 into an overall Medicaid managed care contract, is 13 part of the overall holistic, integrated coverage 14 for physical, behavioral, and long-term services and 15 supports provided to a Medicaid recipient. 16 i. Require each Medicaid managed care organization 17 to verify the offering and actual utilization of 18 services and supports and value-added services, 19 an individual recipient’s encounters and the costs 20 associated with each encounter, and requests and 21 associated approvals or denials of services. 22 Verification of actual receipt of services and supports 23 and value-added services shall, at a minimum, consist 24 of comparing receipt of service against both what 25 was authorized in the recipient’s benefit or service 26 plan and what was actually reimbursed. Value-added 27 services shall not be reportable as allowable medical 28 or administrative costs or factored into rate setting, 29 and the costs of value-added services shall not be 30 passed on to recipients or providers. 31 j. Provide periodic reports to the governor and 32 the general assembly regarding changes in quality of 33 care and health outcomes for Medicaid recipients under 34 managed care compared to quality of care and health 35 -30- HF2460.3521 (3) 86 pf/rn 30/ 43
outcomes of the same populations of Medicaid recipients 1 prior to January 1, 2016. 2 k. Require each Medicaid managed care organization 3 to maintain records of complaints, grievances, and 4 appeals, and report the number and types of complaints, 5 grievances, and appeals filed, the resolution of each, 6 and a description of any patterns or trends identified 7 to the department of human services and the health 8 policy oversight committee created in section 2.45, 9 on a monthly basis. The department shall review and 10 compile the data on a quarterly basis and make the 11 compilations available to the public. Following review 12 of reports submitted by the department, a Medicaid 13 managed care organization shall take any corrective 14 action required by the department and shall be subject 15 to any applicable penalties. 16 l. Require Medicaid managed care organizations to 17 survey Medicaid recipients, to collect satisfaction 18 data using a uniform instrument, and to provide a 19 detailed analysis of recipient satisfaction as well as 20 various metrics regarding the volume of and timelines 21 in responding to recipient complaints and grievances as 22 directed by the department of human services. 23 m. Require managed care organizations to allow a 24 recipient to request that the managed care organization 25 enter into a single case agreement with a recipient’s 26 out-of-network provider, including a provider outside 27 of the state, to provide for continuity of care when 28 the recipient has an existing relationship with the 29 provider to provide a covered benefit, or to ensure 30 adequate or timely access to a provider of a covered 31 benefit when the managed care organization provider 32 network cannot ensure such adequate or timely access. 33 2. CHILDREN. 34 a. (1) The hawk-i board shall retain all authority 35 -31- HF2460.3521 (3) 86 pf/rn 31/ 43
specified under chapter 514I relative to the children 1 eligible under section 514I.8 to participate in the 2 hawk-i program, including but not limited to approving 3 any contract entered into pursuant to chapter 514I; 4 approving the benefit package design, reviewing the 5 benefit package design, and making necessary changes 6 to reflect the results of the reviews; and adopting 7 rules for the hawk-i program including those related 8 to qualifying standards for selecting participating 9 insurers for the program and the benefits to be 10 included in a health plan. 11 (2) The hawk-i board shall review benefit plans 12 and utilization review provisions and ensure that 13 benefits provided to children under the hawk-i program, 14 at a minimum, reflect those required by state law as 15 specified in section 514I.5, include both habilitative 16 and rehabilitative services, and are provided as 17 medically necessary relative to the child population 18 served and based on the needs of the program recipient 19 and the program recipient’s medical history. 20 (3) The hawk-i board shall work with the department 21 of human services to coordinate coverage and care for 22 the population of children in the state eligible for 23 either Medicaid or hawk-i coverage so that, to the 24 greatest extent possible, the two programs provide for 25 continuity of care as children transition between the 26 two programs or to private health care coverage. To 27 this end, all contracts with participating insurers 28 providing coverage under the hawk-i program and with 29 all managed care organizations providing coverage for 30 children eligible for Medicaid shall do all of the 31 following: 32 (a) Specifically and appropriately address 33 the unique needs of children and children’s health 34 delivery. 35 -32- HF2460.3521 (3) 86 pf/rn 32/ 43
(b) Provide for the maintaining of child health 1 panels that include representatives of child health, 2 welfare, policy, and advocacy organizations in the 3 state that address child health and child well-being. 4 (c) Address early intervention and prevention 5 strategies, the provision of a child health care 6 delivery infrastructure for children with special 7 health care needs, utilization of current standards 8 and guidelines for children’s health care and 9 pediatric-specific screening and assessment tools, 10 the inclusion of pediatric specialty providers in 11 the provider network, and the utilization of health 12 homes for children and youth with special health 13 care needs including intensive care coordination 14 and family support and access to a professional 15 family-to-family support system. Such contracts 16 shall utilize pediatric-specific quality measures 17 and assessment tools which shall align with existing 18 pediatric-specific measures as determined in 19 consultation with the child health panel and approved 20 by the hawk-i board. 21 (d) Provide special incentives for innovative 22 and evidence-based preventive, behavioral, and 23 developmental health care and mental health care 24 for children’s programs that improve the life course 25 trajectory of these children. 26 (e) Provide that information collected from the 27 pediatric-specific assessments be used to identify 28 health risks and social determinants of health that 29 impact health outcomes. Such data shall be used in 30 care coordination and interventions to improve patient 31 outcomes and to drive program designs that improve the 32 health of the population. Aggregate assessment data 33 shall be shared with affected providers on a routine 34 basis. 35 -33- HF2460.3521 (3) 86 pf/rn 33/ 43
b. In order to monitor the quality of and access 1 to health care for children receiving coverage under 2 the Medicaid program, each Medicaid managed care 3 organization shall uniformly report, in a template 4 format designated by the department of human services, 5 the number of claims submitted by providers and the 6 percentage of claims approved by the Medicaid managed 7 care organization for the early and periodic screening, 8 diagnostic, and treatment (EPSDT) benefit based 9 on the Iowa EPSDT care for kids health maintenance 10 recommendations, including but not limited to 11 physical exams, immunizations, the seven categories of 12 developmental and behavioral screenings, vision and 13 hearing screenings, and lead testing. 14 3. PROVIDER PARTICIPATION ENHANCEMENT. 15 a. Ensure that savings achieved through Medicaid 16 managed care does not come at the expense of further 17 reductions in provider rates. The department shall 18 ensure that Medicaid managed care organizations use 19 reasonable reimbursement standards for all provider 20 types and compensate providers for covered services at 21 not less than the minimum reimbursement established 22 by state law applicable to fee for service for a 23 respective provider, service, or product for a fiscal 24 year and as determined in conjunction with actuarially 25 sound rate setting procedures. Such reimbursement 26 shall extend for the entire duration of a managed care 27 contract. 28 b. To enhance continuity of care in the provision 29 of pharmacy services, Medicaid managed care 30 organizations shall utilize the same preferred drug 31 list, recommended drug list, prior authorization 32 criteria, and other utilization management strategies 33 that apply to the state program directly under fee for 34 service and shall apply other provisions of applicable 35 -34- HF2460.3521 (3) 86 pf/rn 34/ 43
state law including those relating to chemically unique 1 mental health prescription drugs. Reimbursement rates 2 established under Medicaid managed care contracts for 3 ingredient cost reimbursement and dispensing fees shall 4 be subject to and shall reflect provisions of state 5 and federal law, including the minimum reimbursements 6 established in state law for fee for service for a 7 fiscal year. 8 c. Address rate setting and reimbursement of the 9 entire scope of services provided under the Medicaid 10 program to ensure the adequacy of the provider network 11 and to ensure that providers that contribute to the 12 holistic health of the Medicaid recipient, whether 13 inside or outside of the provider network, are 14 compensated for their services. 15 d. Managed care contractors shall submit financial 16 documentation to the department of human services 17 demonstrating payment of claims and expenses by 18 provider type. 19 e. Participating Medicaid providers under a managed 20 care contract shall be allowed to submit claims for up 21 to 365 days following discharge of a Medicaid recipient 22 from a hospital or following the date of service. 23 f. If the department of human services collects 24 ownership and control information from Medicaid 25 providers pursuant to 42 C.F.R. §455.104, a managed 26 care organization under contract with the state shall 27 not also require submission of this information from 28 approved enrolled Medicaid providers. 29 g. (1) Ensure that a Medicaid managed care 30 organization develops and maintains a provider network 31 of qualified providers who meet state licensing, 32 credentialing, and certification requirements, as 33 applicable, which network shall be sufficient to 34 provide adequate access to all services covered and for 35 -35- HF2460.3521 (3) 86 pf/rn 35/ 43
all populations served under the managed care contract. 1 Medicaid managed care organizations shall incorporate 2 existing and traditional providers, including but 3 not limited to those providers that comprise the Iowa 4 collaborative safety net provider network created in 5 section 135.153, into their provider networks. 6 (2) Ensure that respective Medicaid populations 7 are managed at all times within funding limitations 8 and contract terms. The department shall also 9 monitor service delivery and utilization to ensure 10 the responsibility for provision of services to 11 Medicaid recipients is not shifted to non-Medicaid 12 covered services to attain savings, and that such 13 responsibility is not shifted to mental health and 14 disability services regions, local public health 15 agencies, aging and disability resource centers, 16 or other entities unless agreement to provide, and 17 provision for adequate compensation for, such services 18 is agreed to between the affected entities in advance. 19 h. Medicaid managed care organizations shall 20 provide an enrolled Medicaid provider approved by the 21 department of human services the opportunity to be a 22 participating network provider. 23 i. Medicaid managed care organizations shall 24 include provider appeals and grievance procedures 25 that in part allow a provider to file a grievance 26 independently but on behalf of a Medicaid recipient 27 and to appeal claims denials which, if determined to 28 be based on claims for medically necessary services 29 whether or not denied on an administrative basis, shall 30 receive appropriate payment. 31 j. (1) Medicaid managed care organizations 32 shall include as primary care providers any provider 33 designated by the state as a primary care provider, 34 subject to a provider’s respective state certification 35 -36- HF2460.3521 (3) 86 pf/rn 36/ 43
standards, including but not limited to all of the 1 following: 2 (a) A physician who is a family or general 3 practitioner, a pediatrician, an internist, an 4 obstetrician, or a gynecologist. 5 (b) An advanced registered nurse practitioner. 6 (c) A physician assistant. 7 (d) A chiropractor licensed pursuant to chapter 8 151. 9 (2) A Medicaid managed care organization shall not 10 impose more restrictive, additional, or different scope 11 of practice requirements or standards of practice on a 12 primary care provider than those prescribed by state 13 law as a prerequisite for participation in the managed 14 care organization’s provider network. 15 4. CAPITATION RATES AND MEDICAL LOSS RATIO. 16 a. Capitation rates shall be developed based on all 17 reasonable, appropriate, and attainable costs. Costs 18 that are not reasonable, appropriate, or attainable, 19 including but not limited to improper payment 20 recoveries, shall not be included in the development 21 of capitated rates. 22 b. Capitation rates for Medicaid recipients falling 23 within different rate cells shall not be expected to 24 cross-subsidize one another and the data used to set 25 capitation rates shall be relevant and timely and tied 26 to the appropriate Medicaid population. 27 c. Any increase in capitation rates for managed 28 care contractors is subject to prior statutory approval 29 and shall not exceed three percent over the existing 30 capitation rate in any one-year period or five percent 31 over the existing capitation rate in any two-year 32 period. 33 d. A managed care contract shall impose a minimum 34 Medicaid loss ratio of at least eighty-eight percent. 35 -37- HF2460.3521 (3) 86 pf/rn 37/ 43
In calculating the medical loss ratio, medical costs 1 or benefit expenses shall include only those costs 2 directly related to patient medical care and not 3 ancillary expenses, including but not limited to any 4 of the following: 5 (1) Program integrity activities. 6 (2) Utilization review activities. 7 (3) Fraud prevention activities beyond the scope of 8 those activities necessary to recover incurred claims. 9 (4) Provider network development, education, or 10 management activities. 11 (5) Provider credentialing activities. 12 (6) Marketing expenses. 13 (7) Administrative costs associated with recipient 14 incentives. 15 (8) Clinical data collection activities. 16 (9) Claims adjudication expenses. 17 (10) Customer service or health care professional 18 hotline services addressing nonclinical recipient 19 questions. 20 (11) Value-added or cost-containment services, 21 wellness programs, disease management, and case 22 management or care coordination programs. 23 (12) Health quality improvement activities unless 24 specifically approved as a medical cost by state law. 25 Costs of health quality improvement activities included 26 in determining the medical loss ratio shall be only 27 those activities that are independent improvements 28 measurable in individual patients. 29 (13) Insurer claims review activities. 30 (14) Information technology costs unless they 31 directly and credibly improve the quality of health 32 care and do not duplicate, conflict with, or fail to be 33 compatible with similar health information technology 34 efforts of providers. 35 -38- HF2460.3521 (3) 86 pf/rn 38/ 43
(15) Legal department costs including information 1 technology costs, expenses incurred for review and 2 denial of claims, legal costs related to defending 3 claims, settlements for wrongly denied claims, and 4 costs related to administrative claims handling 5 including salaries of administrative personnel and 6 legal costs. 7 (16) Taxes unrelated to premiums or the provision 8 of medical care. Only state and federal taxes and 9 licensing or regulatory fees relevant to actual 10 premiums collected, not including such taxes and fees 11 as property taxes, taxes on investment income, taxes on 12 investment property, and capital gains taxes, may be 13 included in determining the medical loss ratio. 14 e. (1) Provide enhanced guidance and criteria for 15 defining medical and administrative costs, recoveries, 16 and rebates including pharmacy rebates, and the 17 recording, reporting, and recoupment of such costs, 18 recoveries, and rebates realized. 19 (2) Medicaid managed care organizations shall 20 offset recoveries, rebates, and refunds against 21 medical costs, include only allowable administrative 22 expenses in the determination of administrative costs, 23 report costs related to subcontractors properly, and 24 have complete systems checks and review processes to 25 identify overpayment possibilities. 26 (3) Medicaid managed care contractors shall submit 27 publicly available, comprehensive financial statements 28 to the department of human services to verify that the 29 minimum medical loss ratio is being met and shall be 30 subject to periodic audits. 31 5. DATA AND INFORMATION, EVALUATION, AND OVERSIGHT. 32 a. Develop and administer a clear, detailed policy 33 regarding the collection, storage, integration, 34 analysis, maintenance, retention, reporting, sharing, 35 -39- HF2460.3521 (3) 86 pf/rn 39/ 43
and submission of data and information from the 1 Medicaid managed care organizations and shall require 2 each Medicaid managed care organization to have in 3 place a data and information system to ensure that 4 accurate and meaningful data is available. At a 5 minimum, the data shall allow the department to 6 effectively measure and monitor Medicaid managed care 7 organization performance, quality, outcomes including 8 recipient health outcomes, service utilization, 9 finances, program integrity, the appropriateness 10 of payments, and overall compliance with contract 11 requirements; perform risk adjustments and determine 12 actuarially sound capitation rates and appropriate 13 provider reimbursements; verify that the minimum 14 medical loss ratio is being met; ensure recipient 15 access to and use of services; create quality measures; 16 and provide for program transparency. 17 b. Medicaid managed care organizations shall 18 directly capture and retain and shall report actual and 19 detailed medical claims costs and administrative cost 20 data to the department as specified by the department. 21 Medicaid managed care organizations shall allow the 22 department to thoroughly and accurately monitor the 23 medical claims costs and administrative costs data 24 Medicaid managed care organizations report to the 25 department. 26 c. Any audit of Medicaid managed care contracts 27 shall ensure compliance including with respect to 28 appropriate medical costs, allowable administrative 29 costs, the medical loss ratio, cost recoveries, 30 rebates, overpayments, and with specific contract 31 performance requirements. 32 d. The external quality review organization 33 contracting with the department shall review the 34 Medicaid managed care program to determine if the 35 -40- HF2460.3521 (3) 86 pf/rn 40/ 43
state has sufficient infrastructure and controls in 1 place to effectively oversee the Medicaid managed care 2 organizations and the Medicaid program in order to 3 ensure, at a minimum, compliance with Medicaid managed 4 care organization contracts and to prevent fraud, 5 abuse, and overpayments. The results of any external 6 quality review organization review shall be submitted 7 to the governor, the general assembly, and the health 8 policy oversight committee created in section 2.45. 9 e. Publish benchmark indicators based on Medicaid 10 program outcomes from the fiscal year beginning July 1, 11 2015, to be used to compare outcomes of the Medicaid 12 program as administered by the state program prior 13 to July 1, 2015, to those outcomes of the program 14 under Medicaid managed care. The outcomes shall 15 include a comparison of actual costs of the program 16 as administered prior to and after implementation of 17 Medicaid managed care. The data shall also include 18 specific detail regarding the actual expenses incurred 19 by each managed care organization by specific provider 20 line of service. 21 f. Review and approve or deny approval of contract 22 amendments on an ongoing basis to provide for 23 continuous improvement in Medicaid managed care and 24 to incorporate any changes based on changes in law or 25 policy. 26 g. (1) Require managed care contractors to track 27 and report on a monthly basis to the department of 28 human services, at a minimum, all of the following: 29 (a) The number and details relating to prior 30 authorization requests and denials. 31 (b) The ten most common reasons for claims denials. 32 Information reported by a managed care contractor 33 relative to claims shall also include the number 34 of claims denied, appealed, and overturned based on 35 -41- HF2460.3521 (3) 86 pf/rn 41/ 43
provider type and service type. 1 (c) Utilization of health care services by 2 diagnostic related group and ambulatory payment 3 classification as well as total claims volume. 4 (2) The department shall ensure the validity 5 of all information submitted by a Medicaid managed 6 care organization and shall make the monthly reports 7 available to the public. 8 h. Medicaid managed care organizations shall 9 maintain stakeholder panels comprised of an equal 10 number of Medicaid recipients and providers. Medicaid 11 managed care organizations shall provide for separate 12 provider-specific panels to address detailed payment, 13 claims, process, and other issues as well as grievance 14 and appeals processes. 15 i. Medicaid managed care contracts shall align 16 economic incentives, delivery system reforms, and 17 performance and outcome metrics with those of the state 18 innovation models initiatives and Medicaid accountable 19 care organizations. The department of human services 20 shall develop and utilize a common, uniform set of 21 process, quality, and consumer satisfaction measures 22 across all Medicaid payors and providers that align 23 with those developed through the state innovation 24 models initiative and shall ensure that such measures 25 are expanded and adjusted to address additional 26 populations and to meet population health objectives. 27 Medicaid managed care contracts shall include long-term 28 performance and outcomes goals that reward success in 29 achieving population health goals such as improved 30 community health metrics. 31 j. (1) Require consistency and uniformity of 32 processes, procedures, and forms across all Medicaid 33 managed care organizations to reduce the administrative 34 burden to providers and consumers and to increase 35 -42- HF2460.3521 (3) 86 pf/rn 42/ 43
efficiencies in the program. Such requirements shall 1 apply to but are not limited to areas of uniform cost 2 and quality reporting, uniform prior authorization 3 requirements and procedures, uniform utilization 4 management criteria, centralized, uniform, and seamless 5 credentialing requirements and procedures, and uniform 6 critical incident reporting. 7 (2) The department of human services shall 8 establish a comprehensive provider credentialing 9 process to be recognized and utilized by all Medicaid 10 managed care organization contractors. The process 11 shall meet the national committee for quality assurance 12 and other appropriate standards. The process shall 13 ensure that credentialing is completed in a timely 14 manner without disruption to provider billing 15 processes. 16 k. Medicaid managed care organizations and any 17 entity with which a managed care organization contracts 18 for the performance of services shall disclose at no 19 cost to the department all discounts, incentives, 20 rebates, fees, free goods, bundling arrangements, and 21 other agreements affecting the net cost of goods or 22 services provided under a managed care contract. 23 Sec. ___. RETROACTIVE APPLICABILITY. The section 24 of this division of this Act relating to directives 25 for Medicaid program policy improvements applies 26 retroactively to July 1, 2015. 27 Sec. ___. EFFECTIVE UPON ENACTMENT. This division 28 of this Act, being deemed of immediate importance, 29 takes effect upon enactment. > 30 5. By renumbering as necessary. 31 ______________________________ HEDDENS of Story -43- HF2460.3521 (3) 86 pf/rn 43/ 43 #5.