Senate File 2213 S-5045 Amend Senate File 2213 as follows: 1 1. By striking everything after the enacting clause 2 and inserting: 3 < Section 1. LEGISLATIVE FINDINGS —— GOALS AND 4 INTENT. 5 1. The general assembly finds all of the following: 6 a. In the majority of states, Medicaid managed care 7 has been introduced on an incremental basis, beginning 8 with the enrollment of low-income children and parents 9 and proceeding in stages to include nonelderly persons 10 with disabilities and older individuals. Iowa, unlike 11 the majority of states, is implementing Medicaid 12 managed care hastily and simultaneously across a broad 13 and diverse population that includes individuals with 14 complex health care and long-term services and supports 15 needs, making these individuals especially vulnerable 16 to receiving inappropriate, inadequate, or substandard 17 services and supports. 18 b. The success or failure of Medicaid managed 19 care in Iowa depends on proper strategic planning and 20 strong oversight, and the incorporation of the core 21 values, principles, and goals of the strategic plan 22 into Medicaid managed care contractual obligations. 23 While Medicaid managed care techniques may create 24 pathways and offer opportunities toward quality 25 improvement and predictability in costs, if cost 26 savings and administrative efficiencies are the 27 primary goals, Medicaid managed care may instead erect 28 new barriers and limit the care and support options 29 available, especially to high-need, vulnerable Medicaid 30 recipients. A well-designed strategic plan and 31 effective oversight ensure that cost savings, improved 32 health outcomes, and efficiencies are not achieved 33 at the expense of diminished program integrity, a 34 reduction in the quality or availability of services, 35 -1- SF2213.2830 (2) 86 pf/nh 1/ 48 #1.
or adverse consequences to the health and well-being of 1 Medicaid recipients. 2 c. Strategic planning should include all of the 3 following: 4 (1) Guidance in establishing and maintaining a 5 robust and appropriate workforce and a provider network 6 capable of addressing all of the diverse, distinct, and 7 wide-ranging treatment and support needs of Medicaid 8 recipients. 9 (2) Developing a sound methodology for establishing 10 and adjusting capitation rates to account for all 11 essential costs involved in treating and supporting the 12 entire spectrum of needs across recipient populations. 13 (3) Addressing the sufficiency of information and 14 data resources to enable review of factors such as 15 utilization, service trends, system performance, and 16 outcomes. 17 (4) Building effective working relationships and 18 developing strategies to support community-level 19 integration that provides cross-system coordination 20 and synchronization among the various service sectors, 21 providers, agencies, and organizations to further 22 holistic well-being and population health goals. 23 d. While the contracts entered into between the 24 state and managed care organizations function as a 25 mechanism for enforcing requirements established by the 26 federal and state governments and allow states to shift 27 the financial risk associated with caring for Medicaid 28 recipients to these contractors, the state ultimately 29 retains responsibility for the Medicaid program and 30 the oversight of the performance of the program’s 31 contractors. Administration of the Medicaid program 32 benefits by managed care organizations should not be 33 viewed by state policymakers and state agencies as a 34 means of divesting themselves of their constitutional 35 -2- SF2213.2830 (2) 86 pf/nh 2/ 48
and statutory responsibilities to ensure that 1 recipients of publicly funded services and supports, as 2 well as taxpayers in general, are effectively served. 3 e. Overseeing the performance of Medicaid managed 4 care contractors requires a different set of skills 5 than those required for administering a fee-for-service 6 program. In the absence of the in-house capacity of 7 the department of human services to perform tasks 8 specific to Medicaid managed care oversight, the state 9 essentially cedes its responsibilities to private 10 contractors and relinquishes its accountability to the 11 public. In order to meet these responsibilities, state 12 policymakers must ensure that the state, including the 13 department of human services as the state Medicaid 14 agency, has the authority and resources, including 15 the adequate number of qualified personnel and the 16 necessary tools, to carry out these responsibilities, 17 provide effective administration, and ensure 18 accountability and compliance. 19 f. State policymakers must also ensure that 20 Medicaid managed care contracts contain, at a minimum, 21 clear, unambiguous performance standards, operating 22 guidelines, data collection, maintenance, retention, 23 and reporting requirements, and outcomes expectations 24 so that contractors and subcontractors are held 25 accountable to clear contract specifications. 26 g. As with all system and program redesign efforts 27 undertaken in the state to date, the assumption 28 of the administration of Medicaid program benefits 29 by managed care organizations must involve ongoing 30 stakeholder input and earn the trust and support of 31 these stakeholders. Medicaid recipients, providers, 32 advocates, and other stakeholders have intimate 33 knowledge of the people and processes involved in 34 ensuring the health and safety of Medicaid recipients, 35 -3- SF2213.2830 (2) 86 pf/nh 3/ 48
and are able to offer valuable insight into the 1 barriers likely to be encountered as well as propose 2 solutions for overcoming these obstacles. Local 3 communities and providers of services and supports 4 have firsthand experience working with the Medicaid 5 recipients they serve and are able to identify factors 6 that must be considered to make a system successful. 7 Agencies and organizations that have specific expertise 8 and experience with the services and supports needs of 9 Medicaid recipients and their families are uniquely 10 placed to provide needed assistance in developing 11 the measures for and in evaluating the quality of the 12 program. 13 2. It is the intent of the general assembly that 14 the Medicaid program be implemented and administered, 15 including through Medicaid managed care policies 16 and contract provisions, in a manner that safeguards 17 the interests of Medicaid recipients, encourages the 18 participation of Medicaid providers, and protects 19 the interests of all taxpayers, while attaining the 20 goals of Medicaid modernization to improve quality and 21 access, promote accountability for outcomes, and create 22 a more predictable and sustainable Medicaid budget. 23 HEALTH POLICY OVERSIGHT COMMITTEE 24 Sec. 2. Section 2.45, subsection 6, Code 2016, is 25 amended to read as follows: 26 6. The legislative health policy oversight 27 committee, which shall be composed of ten members of 28 the general assembly, consisting of five members from 29 each house, to be appointed by the legislative council. 30 The legislative health policy oversight committee 31 shall receive updates and review data, public input and 32 concerns, and make recommendations for improvements to 33 and changes in law or rule regarding Medicaid managed 34 care meet at least four times annually to evaluate 35 -4- SF2213.2830 (2) 86 pf/nh 4/ 48
state health policy and provide continuing oversight 1 for publicly funded programs, including but not limited 2 to all facets of the Medicaid and hawk-i programs 3 to, at a minimum, ensure effective and efficient 4 administration of these programs, address stakeholder 5 concerns, monitor program costs and expenditures, and 6 make recommendations relative to the programs . 7 Sec. 3. HEALTH POLICY OVERSIGHT COMMITTEE 8 —— SUBJECT MATTER REVIEW FOR 2016 LEGISLATIVE 9 INTERIM. During the 2016 legislative interim, the 10 health policy oversight committee created in section 11 2.45 shall, as part of the committee’s evaluation 12 of state health policy and review of all facets of 13 the Medicaid and hawk-i programs, review and make 14 recommendations regarding, at a minimum, all of the 15 following: 16 1. The resources and duties of the office of 17 long-term care ombudsman relating to the provision of 18 assistance to and advocacy for Medicaid recipients 19 to determine the designation of duties and level of 20 resources necessary to appropriately address the needs 21 of such individuals. The committee shall consider the 22 health consumer ombudsman alliance report submitted to 23 the general assembly in December 2015, as well as input 24 from the office of long-term care ombudsman and other 25 entities in making recommendations. 26 2. The health benefits and health benefit 27 utilization management criteria for the Medicaid 28 and hawk-i programs to determine the sufficiency 29 and appropriateness of the benefits offered and the 30 utilization of these benefits. 31 3. Prior authorization requirements relative 32 to benefits provided under the Medicaid and hawk-i 33 programs, including but not limited to pharmacy 34 benefits. 35 -5- SF2213.2830 (2) 86 pf/nh 5/ 48
4. Consistency and uniformity in processes, 1 procedures, forms, and other activities across all 2 Medicaid and hawk-i program participating insurers and 3 managed care organizations, including but not limited 4 to cost and quality reporting, credentialing, billing, 5 prior authorization, and critical incident reporting. 6 5. Provider network adequacy including the use of 7 out-of-network and out-of-state providers. 8 6. The role and interplay of other advisory and 9 oversight entities, including but not limited to the 10 medical assistance advisory council and the hawk-i 11 board. 12 REVIEW OF PROGRAM INTEGRITY DUTIES 13 Sec. 4. REVIEW OF PROGRAM INTEGRITY DUTIES —— 14 WORKGROUP —— REPORT. 15 1. The director of human services shall convene 16 a workgroup comprised of members including the 17 commissioner of insurance, the auditor of state, the 18 Medicaid director and bureau chiefs of the managed care 19 organization oversight and supports bureau, the Iowa 20 Medicaid enterprise support bureau, and the medical 21 and long-term services and supports bureau, and a 22 representative of the program integrity unit, or their 23 designees; and representatives of other appropriate 24 state agencies or other entities including but not 25 limited to the office of the attorney general, the 26 office of long-term care ombudsman, and the Medicaid 27 fraud control unit of the investigations division 28 of the department of inspections and appeals. The 29 workgroup shall do all of the following: 30 a. Review the duties of each entity with 31 responsibilities relative to Medicaid program integrity 32 and managed care organizations; review state and 33 federal laws, regulations, requirements, guidance, and 34 policies relating to Medicaid program integrity and 35 -6- SF2213.2830 (2) 86 pf/nh 6/ 48
managed care organizations; and review the laws of 1 other states relating to Medicaid program integrity 2 and managed care organizations. The workgroup shall 3 determine areas of duplication, fragmentation, 4 and gaps; shall identify possible integration, 5 collaboration and coordination of duties; and shall 6 determine whether existing general state Medicaid 7 program and fee-for-service policies, laws, and 8 rules are sufficient, or if changes or more specific 9 policies, laws, and rules are required to provide 10 for comprehensive and effective administration and 11 oversight of the Medicaid program including under the 12 fee-for-service and managed care methodologies. 13 b. Review historical uses of the Medicaid 14 fraud fund created in section 249A.50 and make 15 recommendations for future uses of the moneys in the 16 fund and any changes in law necessary to adequately 17 address program integrity. 18 c. Review medical loss ratio provisions relative 19 to Medicaid managed care contracts and make 20 recommendations regarding, at a minimum, requirements 21 for the necessary collection, maintenance, retention, 22 reporting, and sharing of data and information by 23 Medicaid managed care organizations for effective 24 determination of compliance, and to identify the 25 costs and activities that should be included in the 26 calculation of administrative costs, medical costs or 27 benefit expenses, health quality improvement costs, 28 and other costs and activities incidental to the 29 determination of a medical loss ratio. 30 d. Review the capacity of state agencies, including 31 the need for specialized training and expertise, to 32 address Medicaid and managed care organization program 33 integrity and provide recommendations for the provision 34 of necessary resources and infrastructure, including 35 -7- SF2213.2830 (2) 86 pf/nh 7/ 48
annual budget projections. 1 e. Review the incentives and penalties applicable 2 to violations of program integrity requirements to 3 determine their adequacy in combating waste, fraud, 4 abuse, and other violations that divert limited 5 resources that would otherwise be expended to safeguard 6 the health and welfare of Medicaid recipients, and make 7 recommendations for necessary adjustments to improve 8 compliance. 9 f. Make recommendations regarding the quarterly and 10 annual auditing of financial reports required to be 11 performed for each Medicaid managed care organization 12 to ensure that the activities audited provide 13 sufficient information to the division of insurance 14 of the department of commerce and the department 15 of human services to ensure program integrity. The 16 recommendations shall also address the need for 17 additional audits or other reviews of managed care 18 organizations. 19 g. Review and make recommendations to prohibit 20 cost-shifting between state and local and public and 21 private funding sources for services and supports 22 provided to Medicaid recipients whether directly or 23 indirectly through the Medicaid program. 24 2. The department of human services shall submit 25 a report of the workgroup to the governor, the health 26 policy oversight committee created in section 2.45, 27 and the general assembly initially, on or before 28 November 15, 2016, and on or before November 15, 29 on an annual basis thereafter, to provide findings 30 and recommendations for a coordinated approach 31 to comprehensive and effective administration and 32 oversight of the Medicaid program including under the 33 fee-for-service and managed care methodologies. 34 MEDICAID REINVESTMENT FUND 35 -8- SF2213.2830 (2) 86 pf/nh 8/ 48
Sec. 5. NEW SECTION . 249A.4C Medicaid reinvestment 1 fund. 2 1. A Medicaid reinvestment fund is created in the 3 state treasury under the authority of the department. 4 The department of human services shall collect an 5 initial contribution of five million dollars from each 6 of the managed care organizations contracting with the 7 state during the fiscal year beginning July 1, 2015, 8 for an aggregate amount of fifteen million dollars, 9 and shall deposit such amount in the fund to be used 10 for Medicaid ombudsman activities through the office 11 of long-term care ombudsman. Additionally, moneys 12 from savings realized from the movement of Medicaid 13 recipients from institutional settings to home and 14 community-based services, the portion of the capitation 15 rate withheld from and not returned to Medicaid managed 16 care organizations at the end of each fiscal year, any 17 recouped excess of capitation rates paid to Medicaid 18 managed care organizations, any overpayments recovered 19 under Medicaid managed care contracts, and any other 20 savings realized from Medicaid managed care or from 21 Medicaid program cost-containment efforts, with the 22 exception of the total amount attributable to the 23 projected savings from Medicaid managed care based on 24 the initial capitation rates established for the fiscal 25 year beginning July 1, 2015, shall be credited to the 26 Medicaid reinvestment fund. 27 2. Notwithstanding section 8.33, moneys credited 28 to the fund from any other account or fund shall 29 not revert to the other account or fund. Moneys 30 in the fund shall only be used as provided in 31 appropriations from the fund for the Medicaid program 32 and for health system transformation and integration, 33 including but not limited to providing the necessary 34 infrastructure and resources to protect the interests 35 -9- SF2213.2830 (2) 86 pf/nh 9/ 48
of Medicaid recipients, maintaining adequate provider 1 participation, and ensuring program integrity. Such 2 uses may include but are not limited to: 3 a. Ensuring appropriate reimbursement of Medicaid 4 providers to maintain the type and number of 5 appropriately trained providers necessary to address 6 the needs of Medicaid recipients. 7 b. Providing home and community-based services 8 as necessary to rebalance the long-term services and 9 supports infrastructure and to reduce Medicaid home and 10 community-based services waiver waiting lists. 11 c. Ensuring that a fully functioning independent 12 Medicaid ombudsman program through the office of 13 long-term care ombudsman is available to provide 14 advocacy services and assistance to eligible and 15 potentially eligible Medicaid recipients. 16 d. Ensuring adequate and appropriate capacity of 17 the department of human services as the single state 18 agency designated to administer and supervise the 19 administration of the Medicaid program, to ensure 20 compliance with state and federal law and program 21 integrity requirements. 22 e. Addressing workforce issues to ensure a 23 competent, diverse, and sustainable health care 24 workforce and to improve access to health care in 25 underserved areas and among underserved populations, 26 recognizing long-term services and supports as an 27 essential component of the health care system. 28 f. Supporting innovation, longer-term community 29 investments, and the activities of local public health 30 agencies, aging and disability resource centers and 31 service agencies, mental health and disability services 32 regions, social services, and child welfare entities 33 and other providers of and advocates for services and 34 supports to encourage health system transformation 35 -10- SF2213.2830 (2) 86 pf/nh 10/ 48
and integration through a broad range of prevention 1 strategies and population-based approaches to meet the 2 holistic needs of the population as a whole. 3 3. The department shall establish a mechanism to 4 measure and certify the amount of savings resulting 5 from Medicaid managed care and Medicaid program 6 cost-containment activities and shall ensure that such 7 realized savings are credited to the fund and used as 8 provided in appropriations from the fund. 9 MEDICAID OMBUDSMAN 10 Sec. 6. Section 231.44, Code 2016, is amended to 11 read as follows: 12 231.44 Utilization of resources —— assistance and 13 advocacy related to long-term services and supports 14 under the Medicaid program. 15 1. The office of long-term care ombudsman may 16 shall utilize its available resources to provide 17 assistance and advocacy services to eligible recipients 18 of long-term services and supports , or individuals 19 seeking long-term services and supports, and the 20 families or legal representatives of such eligible 21 recipients, of long-term services and supports provided 22 through individuals under the Medicaid program. Such 23 assistance and advocacy shall include but is not 24 limited to all of the following: 25 a. Assisting recipients such individuals in 26 understanding the services, coverage, and access 27 provisions and their rights under Medicaid managed 28 care. 29 b. Developing procedures for the tracking and 30 reporting of the outcomes of individual requests for 31 assistance, the obtaining of necessary services and 32 supports, and other aspects of the services provided to 33 eligible recipients such individuals . 34 c. Providing advice and assistance relating to the 35 -11- SF2213.2830 (2) 86 pf/nh 11/ 48
preparation and filing of complaints, grievances, and 1 appeals of complaints or grievances, including through 2 processes available under managed care plans and the 3 state appeals process, relating to long-term services 4 and supports under the Medicaid program. 5 d. Accessing the results of a review of a level 6 of care assessment or reassessment by a managed care 7 organization in which the managed care organization 8 recommends denial or limited authorization of a 9 service, including the type or level of service, the 10 reduction, suspension, or termination of a previously 11 authorized service, or a change in level of care, upon 12 the request of an affected individual. 13 e. Receiving notices of disenrollment or notices 14 that would result in a change in level of care for 15 affected individuals, including involuntary and 16 voluntary discharges or transfers, from the department 17 of human services or a managed care organization. 18 2. A representative of the office of long-term care 19 ombudsman providing assistance and advocacy services 20 authorized under this section for an individual, 21 shall be provided access to the individual, and shall 22 be provided access to the individual’s medical and 23 social records as authorized by the individual or the 24 individual’s legal representative, as necessary to 25 carry out the duties specified in this section . 26 3. A representative of the office of long-term care 27 ombudsman providing assistance and advocacy services 28 authorized under this section for an individual, shall 29 be provided access to administrative records related to 30 the provision of the long-term services and supports to 31 the individual, as necessary to carry out the duties 32 specified in this section . 33 4. The office of long-term care ombudsman and 34 representatives of the office, when providing 35 -12- SF2213.2830 (2) 86 pf/nh 12/ 48
assistance and advocacy services under this section, 1 shall be considered a health oversight agency as 2 defined in 45 C.F.R. §164.501 for the purposes of 3 health oversight activities as described in 45 C.F.R. 4 §164.512(d) including access to the health records 5 and other appropriate information of an individual, 6 including from the department of human services or 7 the applicable Medicaid managed care organization, 8 as necessary to fulfill the duties specified under 9 this section. The department of human services, 10 in collaboration with the office of long-term care 11 ombudsman, shall adopt rules to ensure compliance 12 by affected entities with this subsection and to 13 ensure recognition of the office of long-term care 14 ombudsman as a duly authorized and identified agent or 15 representative of the state. 16 5. The department of human services and Medicaid 17 managed care organizations shall inform eligible 18 and potentially eligible Medicaid recipients of the 19 advocacy services and assistance available through the 20 office of long-term care ombudsman and shall provide 21 contact and other information regarding the advocacy 22 services and assistance to eligible and potentially 23 eligible Medicaid recipients as directed by the office 24 of long-term care ombudsman. 25 6. When providing assistance and advocacy services 26 under this section, the office of long-term care 27 ombudsman shall act as an independent agency, and the 28 office of long-term care ombudsman and representatives 29 of the office shall be free of any undue influence that 30 restrains the ability of the office or the office’s 31 representatives from providing such services and 32 assistance. 33 7. The office of long-term care ombudsman shall, in 34 addition to other duties prescribed and at a minimum, 35 -13- SF2213.2830 (2) 86 pf/nh 13/ 48
do all of the following in the furtherance of the 1 provision of advocacy services and assistance under 2 this section: 3 a. Represent the interests of eligible and 4 potentially eligible Medicaid recipients before 5 governmental agencies. 6 b. Analyze, comment on, and monitor the development 7 and implementation of federal, state, and local laws, 8 regulations, and other governmental policies and 9 actions, and recommend any changes in such laws, 10 regulations, policies, and actions as determined 11 appropriate by the office of long-term care ombudsman. 12 c. To maintain transparency and accountability for 13 activities performed under this section, including 14 for the purposes of claiming federal financial 15 participation for activities that are performed to 16 assist with administration of the Medicaid program: 17 (1) Have complete and direct responsibility for the 18 administration, operation, funding, fiscal management, 19 and budget related to such activities, and directly 20 employ, oversee, and supervise all paid and volunteer 21 staff associated with these activities. 22 (2) Establish separation-of-duties requirements, 23 provide limited access to work space and work 24 product for only necessary staff, and limit access to 25 documents and information as necessary to maintain the 26 confidentiality of the protected health information of 27 individuals served under this section. 28 (3) Collect and submit, annually, to the governor, 29 the health policy oversight committee created in 30 section 2.45, and the general assembly, all of the 31 following with regard to those seeking advocacy 32 services or assistance under this section: 33 (a) The number of contacts by contact type and 34 geographic location. 35 -14- SF2213.2830 (2) 86 pf/nh 14/ 48
(b) The type of assistance requested including the 1 name of the managed care organization involved, if 2 applicable. 3 (c) The time frame between the time of the initial 4 contact and when an initial response was provided. 5 (d) The amount of time from the initial contact to 6 resolution of the problem or concern. 7 (e) The actions taken in response to the request 8 for advocacy or assistance. 9 (f) The outcomes of requests to address problems or 10 concerns. 11 4. 8. For the purposes of this section : 12 a. “Institutional setting” includes a long-term care 13 facility, an elder group home, or an assisted living 14 program. 15 b. “Long-term services and supports” means the broad 16 range of health, health-related, and personal care 17 assistance services and supports, provided in both 18 institutional settings and home and community-based 19 settings, necessary for older individuals and persons 20 with disabilities who experience limitations in their 21 capacity for self-care due to a physical, cognitive, or 22 mental disability or condition. 23 Sec. 7. NEW SECTION . 231.44A Willful interference 24 with duties related to long-term services and supports 25 —— penalty. 26 Willful interference with a representative of the 27 office of long-term care ombudsman in the performance 28 of official duties in accordance with section 231.44 29 is a violation of section 231.44, subject to a penalty 30 prescribed by rule. The office of long-term care 31 ombudsman shall adopt rules specifying the amount of a 32 penalty imposed, consistent with the penalties imposed 33 under section 231.42, subsection 8, and specifying 34 procedures for notice and appeal of penalties imposed. 35 -15- SF2213.2830 (2) 86 pf/nh 15/ 48
Any moneys collected pursuant to this section shall be 1 deposited in the Medicaid reinvestment fund created in 2 section 249A.4C. 3 MEDICAL ASSISTANCE ADVISORY COUNCIL 4 Sec. 8. Section 249A.4B, Code 2016, is amended to 5 read as follows: 6 249A.4B Medical assistance advisory council. 7 1. A medical assistance advisory council is 8 created to comply with 42 C.F.R. §431.12 based on 9 section 1902(a)(4) of the federal Social Security Act 10 and to advise the director about health and medical 11 care services under the medical assistance Medicaid 12 program , participate in Medicaid policy development 13 and program administration, and provide guidance on 14 key issues related to the Medicaid program, whether 15 administered under a fee-for-service, managed care, or 16 other methodology, including but not limited to access 17 to care, quality of care, and service delivery . 18 a. The council shall have the opportunity for 19 participation in policy development and program 20 administration, including furthering the participation 21 of recipients of the program, and without limiting this 22 general authority shall specifically do all of the 23 following: 24 (1) Formulate, review, evaluate, and recommend 25 policies, rules, agency initiatives, and legislation 26 pertaining to the Medicaid program. The council shall 27 have the opportunity to comment on proposed rules 28 prior to commencement of the rulemaking process and on 29 waivers and state plan amendment applications. 30 (2) Prior to the annual budget development process, 31 engage in setting priorities, including consideration 32 of the scope and utilization management criteria 33 for benefits, beneficiary eligibility, provider and 34 services reimbursement rates, and other budgetary 35 -16- SF2213.2830 (2) 86 pf/nh 16/ 48
issues. 1 (3) Provide oversight for and review of the 2 administration of the Medicaid program. 3 (4) Ensure that the membership of the council 4 effectively represents all relevant and concerned 5 viewpoints, particularly those of consumers, providers, 6 and the general public; create public understanding; 7 and ensure that the services provided under the 8 Medicaid program meet the needs of the people served. 9 b. The council shall meet no more than at least 10 quarterly , and prior to the next subsequent meeting 11 of the executive committee . The director of public 12 health The public member acting as a co-chairperson 13 of the executive committee and the professional or 14 business entity member acting as a co-chairperson of 15 the executive committee, shall serve as chairperson 16 co-chairpersons of the council. 17 2. The council shall include all of the following 18 voting members: 19 a. The president, or the president’s 20 representative, of each of the following professional 21 or business entities, or a member of each of the 22 following professional or business entities, selected 23 by the entity: 24 (1) The Iowa medical society. 25 (2) The Iowa osteopathic medical association. 26 (3) The Iowa academy of family physicians. 27 (4) The Iowa chapter of the American academy of 28 pediatrics. 29 (5) The Iowa physical therapy association. 30 (6) The Iowa dental association. 31 (7) The Iowa nurses association. 32 (8) The Iowa pharmacy association. 33 (9) The Iowa podiatric medical society. 34 (10) The Iowa optometric association. 35 -17- SF2213.2830 (2) 86 pf/nh 17/ 48
(11) The Iowa association of community providers. 1 (12) The Iowa psychological association. 2 (13) The Iowa psychiatric society. 3 (14) The Iowa chapter of the national association 4 of social workers. 5 (15) The coalition for family and children’s 6 services in Iowa. 7 (16) The Iowa hospital association. 8 (17) The Iowa association of rural health clinics. 9 (18) The Iowa primary care association. 10 (19) Free clinics of Iowa. 11 (20) The opticians’ association of Iowa, inc. 12 (21) The Iowa association of hearing health 13 professionals. 14 (22) The Iowa speech and hearing association. 15 (23) The Iowa health care association. 16 (24) The Iowa association of area agencies on 17 aging. 18 (25) AARP. 19 (26) The Iowa caregivers association. 20 (27) The Iowa coalition of home and community-based 21 services for seniors. 22 (28) The Iowa adult day services association. 23 (29) Leading age Iowa. 24 (30) The Iowa association for home care. 25 (31) The Iowa council of health care centers. 26 (32) The Iowa physician assistant society. 27 (33) The Iowa association of nurse practitioners. 28 (34) The Iowa nurse practitioner society. 29 (35) The Iowa occupational therapy association. 30 (36) The ARC of Iowa, formerly known as the 31 association for retarded citizens of Iowa. 32 (37) The national alliance for the mentally ill on 33 mental illness of Iowa. 34 (38) The Iowa state association of counties. 35 -18- SF2213.2830 (2) 86 pf/nh 18/ 48
(39) The Iowa developmental disabilities council. 1 (40) The Iowa chiropractic society. 2 (41) The Iowa academy of nutrition and dietetics. 3 (42) The Iowa behavioral health association. 4 (43) The midwest association for medical equipment 5 services or an affiliated Iowa organization. 6 (44) The Iowa public health association. 7 (45) The epilepsy foundation. 8 b. Public representatives which may include members 9 of consumer groups, including recipients of medical 10 assistance or their families, consumer organizations, 11 and others, which shall be appointed by the governor 12 in equal in number to the number of representatives of 13 the professional and business entities specifically 14 represented under paragraph “a” , appointed by the 15 governor for staggered terms of two years each, none 16 of whom shall be members of, or practitioners of, or 17 have a pecuniary interest in any of the professional 18 or business entities specifically represented under 19 paragraph “a” , and a majority of whom shall be current 20 or former recipients of medical assistance or members 21 of the families of current or former recipients. 22 3. The council shall include all of the following 23 nonvoting members: 24 c. a. The director of public health, or the 25 director’s designee. 26 d. b. The director of the department on aging, or 27 the director’s designee. 28 c. The state long-term care ombudsman, or the 29 ombudsman’s designee. 30 d. The ombudsman appointed pursuant to section 31 2C.3, or the ombudsman’s designee. 32 e. The dean of Des Moines university —— osteopathic 33 medical center, or the dean’s designee. 34 f. The dean of the university of Iowa college of 35 -19- SF2213.2830 (2) 86 pf/nh 19/ 48
medicine, or the dean’s designee. 1 g. The following members of the general assembly, 2 each for a term of two years as provided in section 3 69.16B : 4 (1) Two members of the house of representatives, 5 one appointed by the speaker of the house of 6 representatives and one appointed by the minority 7 leader of the house of representatives from their 8 respective parties. 9 (2) Two members of the senate, one appointed by the 10 president of the senate after consultation with the 11 majority leader of the senate and one appointed by the 12 minority leader of the senate. 13 3. 4. a. An executive committee of the council is 14 created and shall consist of the following members of 15 the council: 16 (1) As voting members: 17 (a) Five of the professional or business entity 18 members designated pursuant to subsection 2 , paragraph 19 “a” , and selected by the members specified under that 20 paragraph. 21 (2) (b) Five of the public members appointed 22 pursuant to subsection 2 , paragraph “b” , and selected 23 by the members specified under that paragraph. Of the 24 five public members, at least one member shall be a 25 recipient of medical assistance. 26 (3) (2) As nonvoting members: 27 (a) The director of public health, or the 28 director’s designee. 29 (b) The director of the department on aging, or the 30 director’s designee. 31 (c) The state long-term care ombudsman, or the 32 ombudsman’s designee. 33 (d) The ombudsman appointed pursuant to section 34 2C.3, or the ombudsman’s designee. 35 -20- SF2213.2830 (2) 86 pf/nh 20/ 48
b. The executive committee shall meet on a monthly 1 basis. The director of public health A public member 2 of the executive committee selected by the public 3 members appointed pursuant to subsection 2, paragraph 4 “b” , and a professional or business entity member of 5 the executive committee selected by the professional 6 or business entity members appointed pursuant to 7 subsection 2, paragraph “a” , shall serve as chairperson 8 co-chairpersons of the executive committee. 9 c. Based upon the deliberations of the council , 10 and the executive committee, and the subcommittees, 11 the executive committee , the council, and the 12 subcommittees, respectively, shall make recommendations 13 to the director , to the health policy oversight 14 committee created in section 2.45, to the general 15 assembly’s joint appropriations subcommittee on health 16 and human services, and to the general assembly’s 17 standing committees on human resources regarding the 18 budget, policy, and administration of the medical 19 assistance program. 20 5. a. The council shall create the following 21 subcommittees, and may create additional subcommittees 22 as necessary to address Medicaid program policies, 23 administration, budget, and other factors and issues: 24 (1) A stakeholder safeguards subcommittee, for 25 which the co-chairpersons shall be a public member 26 of the council appointed pursuant to subsection 2, 27 paragraph “b” , and selected by the public members of 28 the council, and a representative of a professional 29 or business entity appointed pursuant to subsection 30 2, paragraph “a” , and selected by the professional or 31 business entity representatives of the council. The 32 mission of the stakeholder safeguards subcommittee 33 is to provide for ongoing stakeholder engagement and 34 feedback on issues affecting Medicaid recipients, 35 -21- SF2213.2830 (2) 86 pf/nh 21/ 48
providers, and other stakeholders, including but not 1 limited to benefits such as transportation, benefit 2 utilization management, the inclusion of out-of-state 3 and out-of-network providers and the use of single-case 4 agreements, and reimbursement of providers and 5 services. 6 (2) The long-term services and supports 7 subcommittee which shall be chaired by the state 8 long-term care ombudsman, or the ombudsman’s designee. 9 The mission of the long-term services and supports 10 subcommittee is to be a resource and to provide advice 11 on policy development and program administration 12 relating to Medicaid long-term services and supports 13 including but not limited to developing outcomes and 14 performance measures for Medicaid managed care for the 15 long-term services and supports population; addressing 16 issues related to home and community-based services 17 waivers and waiting lists; and reviewing the system of 18 long-term services and supports to ensure provision of 19 home and community-based services and the rebalancing 20 of the health care infrastructure in accordance with 21 state and federal law including but not limited to the 22 principles established in Olmstead v. L.C., 527 U.S. 23 581 (1999) and the federal Americans with Disabilities 24 Act and in a manner that reflects a sustainable, 25 person-centered approach to improve health and life 26 outcomes, supports maximum independence, addresses 27 medical and social needs in a coordinated, integrated 28 manner, and provides for sufficient resources including 29 a stable, well-qualified workforce. The subcommittee 30 shall also address and make recommendations regarding 31 the need for an ombudsman function for eligible and 32 potentially eligible Medicaid recipients beyond the 33 long-term services and supports population. 34 (3) The transparency, data, and program evaluation 35 -22- SF2213.2830 (2) 86 pf/nh 22/ 48
subcommittee which shall be chaired by the director of 1 the university of Iowa public policy center, or the 2 director’s designee. The mission of the transparency, 3 data, and program evaluation subcommittee is to 4 ensure Medicaid program transparency; ensure the 5 collection, maintenance, retention, reporting, and 6 analysis of sufficient and meaningful data to provide 7 transparency and inform policy development and program 8 effectiveness; support development and administration 9 of a consumer-friendly dashboard; and promote the 10 ongoing evaluation of Medicaid stakeholder satisfaction 11 with the Medicaid program. 12 (4) The program integrity subcommittee which shall 13 be chaired by the Medicaid director, or the director’s 14 designee. The mission of the program integrity 15 subcommittee is to ensure that a comprehensive system 16 including specific policies, laws, and rules and 17 adequate resources and measures are in place to 18 effectively administer the program and to maintain 19 compliance with federal and state program integrity 20 requirements. 21 (5) A health workforce subcommittee, co-chaired 22 by the bureau chief of the bureau of oral and health 23 delivery systems of the department of public health, 24 or the bureau chief’s designee, and the director of 25 the national alliance on mental illness of Iowa, or 26 the director’s designee. The mission of the health 27 workforce subcommittee is to assess the sufficiency 28 and proficiency of the current and projected health 29 workforce; identify barriers to and gaps in health 30 workforce development initiatives and health 31 workforce data to provide foundational, evidence-based 32 information to inform policymaking and resource 33 allocation; evaluate the most efficient application 34 and utilization of roles, functions, responsibilities, 35 -23- SF2213.2830 (2) 86 pf/nh 23/ 48
activities, and decision-making capacity of health 1 care professionals and other allied and support 2 personnel; and make recommendations for improvement 3 in, and alternative modes of, health care delivery in 4 order to provide a competent, diverse, and sustainable 5 health workforce in the state. The subcommittee shall 6 work in collaboration with the office of statewide 7 clinical education programs of the university of Iowa 8 Carver college of medicine, Des Moines university, 9 Iowa workforce development, and other entities with 10 interest or expertise in the health workforce in 11 carrying out the subcommittee’s duties and developing 12 recommendations. 13 b. The co-chairpersons of the council shall 14 appoint members to each subcommittee from the general 15 membership of the council. Consideration in appointing 16 subcommittee members shall include the individual’s 17 knowledge about, and interest or expertise in, matters 18 that come before the subcommittee. 19 c. Subcommittees shall meet at the call of the 20 co-chairpersons or chairperson of the subcommittee, 21 or at the request of a majority of the members of the 22 subcommittee. 23 4. 6. For each council meeting, executive 24 committee meeting, or subcommittee meeting, a quorum 25 shall consist of fifty percent of the membership 26 qualified to vote. Where a quorum is present, a 27 position is carried by a majority of the members 28 qualified to vote. 29 7. For each council meeting, other than those 30 held during the time the general assembly is in 31 session, each legislative member of the council shall 32 be reimbursed for actual travel and other necessary 33 expenses and shall receive a per diem as specified in 34 section 7E.6 for each day in attendance, as shall the 35 -24- SF2213.2830 (2) 86 pf/nh 24/ 48
members of the council , or the executive committee , 1 or a subcommittee, for each day in attendance at a 2 council, executive committee, or subcommittee meeting, 3 who are recipients or the family members of recipients 4 of medical assistance, regardless of whether the 5 general assembly is in session. 6 5. 8. The department shall provide staff support 7 and independent technical assistance to the council , 8 and the executive committee , and the subcommittees . 9 6. 9. The director shall consider comply with 10 the requirements of this section regarding the 11 duties of the council, and the deliberations and 12 recommendations offered by of the council , and the 13 executive committee , and the subcommittees shall be 14 reflected in the director’s preparation of medical 15 assistance budget recommendations to the council 16 on human services pursuant to section 217.3 , and in 17 implementation of medical assistance program policies , 18 and in administration of the Medicaid program . 19 10. The council, executive committee, and 20 subcommittees shall jointly submit quarterly reports 21 to the health policy oversight committee created in 22 section 2.45 and shall jointly submit a report to the 23 governor and the general assembly initially by January 24 1, 2017, and annually, therefore, summarizing the 25 outcomes and findings of their respective deliberations 26 and any recommendations including but not limited to 27 those for changes in law or policy. 28 11. The council, executive committee, and 29 subcommittees may enlist the services of persons who 30 are qualified by education, expertise, or experience 31 to advise, consult with, or otherwise assist the 32 council, executive committee, or subcommittees in the 33 performance of their duties. The council, executive 34 committee, or subcommittees may specifically enlist 35 -25- SF2213.2830 (2) 86 pf/nh 25/ 48
the assistance of entities such as the university of 1 Iowa public policy center to provide ongoing evaluation 2 of the Medicaid program and to make evidence-based 3 recommendations to improve the program. The council, 4 executive committee, and subcommittees shall enlist 5 input from the patient-centered health advisory council 6 created in section 135.159, the mental health and 7 disabilities services commission created in section 8 225C.5, the commission on aging created in section 9 231.11, the bureau of substance abuse of the department 10 of public health, the Iowa developmental disabilities 11 council, and other appropriate state and local entities 12 to provide advice to the council, executive committee, 13 and subcommittees. 14 12. The department, in accordance with 42 C.F.R. 15 §431.12, shall seek federal financial participation for 16 the activities of the council, the executive committee, 17 and the subcommittees. 18 PATIENT-CENTERED HEALTH RESOURCES AND INFRASTRUCTURE 19 Sec. 9. Section 135.159, subsection 2, Code 2016, 20 is amended to read as follows: 21 2. a. The department shall establish a 22 patient-centered health advisory council which shall 23 include but is not limited to all of the following 24 members, selected by their respective organizations, 25 and any other members the department determines 26 necessary to assist in the department’s duties at 27 various stages of development of the medical home 28 system and in the transformation to a patient-centered 29 infrastructure that integrates and coordinates services 30 and supports to address social determinants of health 31 and meet population health goals : 32 (1) The director of human services, or the 33 director’s designee. 34 (2) The commissioner of insurance, or the 35 -26- SF2213.2830 (2) 86 pf/nh 26/ 48
commissioner’s designee. 1 (3) A representative of the federation of Iowa 2 insurers. 3 (4) A representative of the Iowa dental 4 association. 5 (5) A representative of the Iowa nurses 6 association. 7 (6) A physician and an osteopathic physician 8 licensed pursuant to chapter 148 who are family 9 physicians and members of the Iowa academy of family 10 physicians. 11 (7) A health care consumer. 12 (8) A representative of the Iowa collaborative 13 safety net provider network established pursuant to 14 section 135.153 . 15 (9) A representative of the Iowa developmental 16 disabilities council. 17 (10) A representative of the Iowa chapter of the 18 American academy of pediatrics. 19 (11) A representative of the child and family 20 policy center. 21 (12) A representative of the Iowa pharmacy 22 association. 23 (13) A representative of the Iowa chiropractic 24 society. 25 (14) A representative of the university of Iowa 26 college of public health. 27 (15) A representative of the Iowa public health 28 association. 29 (16) A representative of the area agencies on 30 aging. 31 (17) A representative of the mental health and 32 disability services regions. 33 (18) A representative of early childhood Iowa. 34 b. Public members of the patient-centered health 35 -27- SF2213.2830 (2) 86 pf/nh 27/ 48
advisory council shall receive reimbursement for 1 actual expenses incurred while serving in their 2 official capacity only if they are not eligible for 3 reimbursement by the organization that they represent. 4 c. (1) Beginning July 1, 2016, the 5 patient-centered health advisory council shall 6 do all of the following: 7 (a) Review and make recommendations to the 8 department and to the general assembly regarding 9 the building of effective working relationships and 10 strategies to support state-level and community-level 11 integration, to provide cross-system coordination 12 and synchronization, and to more appropriately align 13 health delivery models and service sectors, including 14 but not limited to public health, aging and disability 15 services agencies, mental health and disability 16 services regions, social services, child welfare, and 17 other providers, agencies, organizations, and sectors 18 to address social determinants of health, holistic 19 well-being, and population health goals. Such review 20 and recommendations shall include a review of funding 21 streams and recommendations for blending and braiding 22 funding to support these efforts. 23 (b) Assist in efforts to evaluate the health 24 workforce to inform policymaking and resource 25 allocation. 26 (2) The patient-centered health advisory council 27 shall submit a report to the department, the health 28 policy oversight committee created in section 2.45, and 29 the general assembly, initially, on or before December 30 15, 2016, and on or before December 15, annually, 31 thereafter, including any findings or recommendations 32 resulting from the council’s deliberations. 33 HAWK-I PROGRAM 34 Sec. 10. Section 514I.5, subsection 8, paragraph 35 -28- SF2213.2830 (2) 86 pf/nh 28/ 48
d, Code 2016, is amended by adding the following new 1 subparagraph: 2 NEW SUBPARAGRAPH . (17) Occupational therapy. 3 Sec. 11. Section 514I.5, subsection 8, Code 2016, 4 is amended by adding the following new paragraph: 5 NEW PARAGRAPH . m. The definition of medically 6 necessary and the utilization management criteria under 7 the hawk-i program in order to ensure that benefits 8 are uniformly and consistently provided across all 9 participating insurers in the type and manner that 10 reflects and appropriately meets the needs, including 11 but not limited to the habilitative and rehabilitative 12 needs, of the child population including those children 13 with special health care needs. 14 MEDICAID PROGRAM POLICY IMPROVEMENT 15 Sec. 12. DIRECTIVES FOR MEDICAID PROGRAM POLICY 16 IMPROVEMENTS. In order to safeguard the interests 17 of Medicaid recipients, encourage the participation 18 of Medicaid providers, and protect the interests 19 of all taxpayers, the department of human services 20 shall comply with or ensure that the specified entity 21 complies with all of the following and shall amend 22 Medicaid managed care contract provisions as necessary 23 to reflect all of the following: 24 1. CONSUMER PROTECTIONS. 25 a. In accordance with 42 C.F.R. §438.420, a 26 Medicaid managed care organization shall continue a 27 recipient’s benefits during an appeal process. If, as 28 allowed when final resolution of an appeal is adverse 29 to the Medicaid recipient, the Medicaid managed care 30 organization chooses to recover the costs of the 31 services furnished to the recipient while an appeal is 32 pending, the Medicaid managed care organization shall 33 provide adequate prior notice of potential recovery 34 of costs to the recipient at the time the appeal is 35 -29- SF2213.2830 (2) 86 pf/nh 29/ 48
filed, and any costs recovered shall be remitted to 1 the department of human services and deposited in the 2 Medicaid reinvestment fund created in section 249A.4C. 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 deposited in the 26 Medicaid reinvestment fund created in section 249A.4C. 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 -30- SF2213.2830 (2) 86 pf/nh 30/ 48
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 -31- SF2213.2830 (2) 86 pf/nh 31/ 48
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 -32- SF2213.2830 (2) 86 pf/nh 32/ 48
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 -33- SF2213.2830 (2) 86 pf/nh 33/ 48
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 -34- SF2213.2830 (2) 86 pf/nh 34/ 48
(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 -35- SF2213.2830 (2) 86 pf/nh 35/ 48
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 -36- SF2213.2830 (2) 86 pf/nh 36/ 48
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. (1) A managed care contract entered into on 24 or after July 1, 2015, shall, at a minimum, reflect 25 all of the following provisions and requirements, and 26 shall extend the following payment rates based on the 27 specified payment floor, as applicable to the provider 28 type: 29 (a) In calculating the rates for prospective 30 payment system hospitals, the following base rates 31 shall be used: 32 (i) The inpatient diagnostic related group base 33 rates and certified unit per diem in effect on October 34 1, 2015. 35 -37- SF2213.2830 (2) 86 pf/nh 37/ 48
(ii) The outpatient ambulatory payment 1 classification base rates in effect on July 1, 2015. 2 (iii) The inpatient psychiatric certified unit per 3 diem in effect on October 1, 2015. 4 (iv) The inpatient physical rehabilitation 5 certified unit per diem in effect on October 1, 2015. 6 (b) In calculating the critical access hospital 7 payment rates, the following base rates shall be used: 8 (i) The inpatient diagnostic related group base 9 rates in effect on July 1, 2015. 10 (ii) The outpatient cost-to-charge ratio in effect 11 on July 1, 2015. 12 (iii) The swing bed per diem in effect on July 1, 13 2015. 14 (c) Critical access hospitals shall receive 15 cost-based reimbursement for one hundred percent of 16 the reasonable costs for the provision of services to 17 Medicaid recipients. 18 (d) Critical access hospitals shall submit annual 19 cost reports and managed care contractors shall submit 20 annual payment reports to the department of human 21 services. The department shall reconcile the critical 22 access hospital’s reported costs with the managed care 23 contractor’s reported payments. The department shall 24 require the managed care contractor to retroactively 25 reimburse a critical access hospital for underpayments. 26 (e) Community mental health centers shall receive 27 one hundred percent of the reasonable costs for the 28 provision of services to Medicaid recipients. 29 (f) Federally qualified health centers shall 30 receive cost-based reimbursement for one hundred 31 percent of the reasonable costs for the provision of 32 services to Medicaid recipients. 33 (g) The reimbursement rates for substance-related 34 disorder treatment programs licensed under section 35 -38- SF2213.2830 (2) 86 pf/nh 38/ 48
125.13, shall be no lower than the rates in effect for 1 the fiscal year beginning July 1, 2015. 2 (2) For managed care contract periods subsequent to 3 the initial contract period, base rates for prospective 4 payment system hospitals and critical access hospitals 5 shall be calculated using the base rate for the prior 6 contract period plus 3 percent. Prospective payment 7 system hospital and critical access hospital base rates 8 shall at no time be less than the previous contract 9 period’s base rates. 10 (3) A managed care contract shall require 11 out-of-network prospective payment system hospital 12 and critical access hospital payment rates to meet or 13 exceed ninety-nine percent of the rates specified for 14 the respective in-network hospitals in accordance with 15 this paragraph “f”. 16 g. If the department of human services collects 17 ownership and control information from Medicaid 18 providers pursuant to 42 C.F.R. §455.104, a managed 19 care organization under contract with the state shall 20 not also require submission of this information from 21 approved enrolled Medicaid providers. 22 h. (1) Ensure that a Medicaid managed care 23 organization develops and maintains a provider network 24 of qualified providers who meet state licensing, 25 credentialing, and certification requirements, as 26 applicable, which network shall be sufficient to 27 provide adequate access to all services covered and for 28 all populations served under the managed care contract. 29 Medicaid managed care organizations shall incorporate 30 existing and traditional providers, including but 31 not limited to those providers that comprise the Iowa 32 collaborative safety net provider network created in 33 section 135.153, into their provider networks. 34 (2) Ensure that respective Medicaid populations 35 -39- SF2213.2830 (2) 86 pf/nh 39/ 48
are managed at all times within funding limitations 1 and contract terms. The department shall also 2 monitor service delivery and utilization to ensure 3 the responsibility for provision of services to 4 Medicaid recipients is not shifted to non-Medicaid 5 covered services to attain savings, and that such 6 responsibility is not shifted to mental health and 7 disability services regions, local public health 8 agencies, aging and disability resource centers, 9 or other entities unless agreement to provide, and 10 provision for adequate compensation for, such services 11 is agreed to between the affected entities in advance. 12 i. Medicaid managed care organizations shall 13 provide an enrolled Medicaid provider approved by the 14 department of human services the opportunity to be a 15 participating network provider. 16 j. Medicaid managed care organizations shall 17 include provider appeals and grievance procedures 18 that in part allow a provider to file a grievance 19 independently but on behalf of a Medicaid recipient 20 and to appeal claims denials which, if determined to 21 be based on claims for medically necessary services 22 whether or not denied on an administrative basis, shall 23 receive appropriate payment. 24 k. (1) Medicaid managed care organizations 25 shall include as primary care providers any provider 26 designated by the state as a primary care provider, 27 subject to a provider’s respective state certification 28 standards, including but not limited to all of the 29 following: 30 (a) A physician who is a family or general 31 practitioner, a pediatrician, an internist, an 32 obstetrician, or a gynecologist. 33 (b) An advanced registered nurse practitioner. 34 (c) A physician assistant. 35 -40- SF2213.2830 (2) 86 pf/nh 40/ 48
(d) A chiropractor licensed pursuant to chapter 1 151. 2 (2) A Medicaid managed care organization shall not 3 impose more restrictive, additional, or different scope 4 of practice requirements or standards of practice on a 5 primary care provider than those prescribed by state 6 law as a prerequisite for participation in the managed 7 care organization’s provider network. 8 4. CAPITATION RATES AND MEDICAL LOSS RATIO. 9 a. Capitation rates shall be developed based on all 10 reasonable, appropriate, and attainable costs. Costs 11 that are not reasonable, appropriate, or attainable, 12 including but not limited to improper payment 13 recoveries, shall not be included in the development 14 of capitated rates. 15 b. Capitation rates for Medicaid recipients falling 16 within different rate cells shall not be expected to 17 cross-subsidize one another and the data used to set 18 capitation rates shall be relevant and timely and tied 19 to the appropriate Medicaid population. 20 c. Any increase in capitation rates for managed 21 care contractors is subject to prior statutory approval 22 and shall not exceed three percent over the existing 23 capitation rate in any one-year period or five percent 24 over the existing capitation rate in any two-year 25 period. 26 d. In addition to withholding two percent of a 27 managed care organization’s annual capitation payment 28 as a pay-for-performance enforcement mechanism, the 29 department of human services shall also withhold an 30 additional two percent of a managed care organization’s 31 annual capitation payment until the department is able 32 to ensure that the respective managed care organization 33 has complied with all requirements relating to data, 34 information, transparency, evaluation, and oversight 35 -41- SF2213.2830 (2) 86 pf/nh 41/ 48
specified by law, rule, contract, or other basis. 1 e. The department of human services shall collect 2 an initial contribution of five million dollars from 3 each of the managed care organizations contracting 4 with the state during the fiscal year beginning July 5 1, 2015, for an aggregate amount of fifteen million 6 dollars, and shall deposit such amount in the Medicaid 7 reinvestment fund, as provided in section 249A.4C, as 8 enacted in this Act, to be used for Medicaid ombudsman 9 activities through the office of long-term care 10 ombudsman. 11 f. A managed care contract shall impose a minimum 12 Medicaid loss ratio of at least eighty-eight percent. 13 In calculating the medical loss ratio, medical costs 14 or benefit expenses shall include only those costs 15 directly related to patient medical care and not 16 ancillary expenses, including but not limited to any 17 of the following: 18 (1) Program integrity activities. 19 (2) Utilization review activities. 20 (3) Fraud prevention activities beyond the scope of 21 those activities necessary to recover incurred claims. 22 (4) Provider network development, education, or 23 management activities. 24 (5) Provider credentialing activities. 25 (6) Marketing expenses. 26 (7) Administrative costs associated with recipient 27 incentives. 28 (8) Clinical data collection activities. 29 (9) Claims adjudication expenses. 30 (10) Customer service or health care professional 31 hotline services addressing nonclinical recipient 32 questions. 33 (11) Value-added or cost-containment services, 34 wellness programs, disease management, and case 35 -42- SF2213.2830 (2) 86 pf/nh 42/ 48
management or care coordination programs. 1 (12) Health quality improvement activities unless 2 specifically approved as a medical cost by state law. 3 Costs of health quality improvement activities included 4 in determining the medical loss ratio shall be only 5 those activities that are independent improvements 6 measurable in individual patients. 7 (13) Insurer claims review activities. 8 (14) Information technology costs unless they 9 directly and credibly improve the quality of health 10 care and do not duplicate, conflict with, or fail to be 11 compatible with similar health information technology 12 efforts of providers. 13 (15) Legal department costs including information 14 technology costs, expenses incurred for review and 15 denial of claims, legal costs related to defending 16 claims, settlements for wrongly denied claims, and 17 costs related to administrative claims handling 18 including salaries of administrative personnel and 19 legal costs. 20 (16) Taxes unrelated to premiums or the provision 21 of medical care. Only state and federal taxes and 22 licensing or regulatory fees relevant to actual 23 premiums collected, not including such taxes and fees 24 as property taxes, taxes on investment income, taxes on 25 investment property, and capital gains taxes, may be 26 included in determining the medical loss ratio. 27 g. (1) Provide enhanced guidance and criteria for 28 defining medical and administrative costs, recoveries, 29 and rebates including pharmacy rebates, and the 30 recording, reporting, and recoupment of such costs, 31 recoveries, and rebates realized. 32 (2) Medicaid managed care organizations shall 33 offset recoveries, rebates, and refunds against 34 medical costs, include only allowable administrative 35 -43- SF2213.2830 (2) 86 pf/nh 43/ 48
expenses in the determination of administrative costs, 1 report costs related to subcontractors properly, and 2 have complete systems checks and review processes to 3 identify overpayment possibilities. 4 (3) Medicaid managed care contractors shall submit 5 publicly available, comprehensive financial statements 6 to the department of human services to verify that the 7 minimum medical loss ratio is being met and shall be 8 subject to periodic audits. 9 5. DATA AND INFORMATION, EVALUATION, AND OVERSIGHT. 10 a. Develop and administer a clear, detailed policy 11 regarding the collection, storage, integration, 12 analysis, maintenance, retention, reporting, sharing, 13 and submission of data and information from the 14 Medicaid managed care organizations and shall require 15 each Medicaid managed care organization to have in 16 place a data and information system to ensure that 17 accurate and meaningful data is available. At a 18 minimum, the data shall allow the department to 19 effectively measure and monitor Medicaid managed care 20 organization performance, quality, outcomes including 21 recipient health outcomes, service utilization, 22 finances, program integrity, the appropriateness 23 of payments, and overall compliance with contract 24 requirements; perform risk adjustments and determine 25 actuarially sound capitation rates and appropriate 26 provider reimbursements; verify that the minimum 27 medical loss ratio is being met; ensure recipient 28 access to and use of services; create quality measures; 29 and provide for program transparency. 30 b. Medicaid managed care organizations shall 31 directly capture and retain and shall report actual and 32 detailed medical claims costs and administrative cost 33 data to the department as specified by the department. 34 Medicaid managed care organizations shall allow the 35 -44- SF2213.2830 (2) 86 pf/nh 44/ 48
department to thoroughly and accurately monitor the 1 medical claims costs and administrative costs data 2 Medicaid managed care organizations report to the 3 department. 4 c. Any audit of Medicaid managed care contracts 5 shall ensure compliance including with respect to 6 appropriate medical costs, allowable administrative 7 costs, the medical loss ratio, cost recoveries, 8 rebates, overpayments, and with specific contract 9 performance requirements. 10 d. The external quality review organization 11 contracting with the department shall review the 12 Medicaid managed care program to determine if the 13 state has sufficient infrastructure and controls in 14 place to effectively oversee the Medicaid managed care 15 organizations and the Medicaid program in order to 16 ensure, at a minimum, compliance with Medicaid managed 17 care organization contracts and to prevent fraud, 18 abuse, and overpayments. The results of any external 19 quality review organization review shall be submitted 20 to the governor, the general assembly, and the health 21 policy oversight committee created in section 2.45. 22 e. Publish benchmark indicators based on Medicaid 23 program outcomes from the fiscal year beginning July 1, 24 2015, to be used to compare outcomes of the Medicaid 25 program as administered by the state program prior 26 to July 1, 2015, to those outcomes of the program 27 under Medicaid managed care. The outcomes shall 28 include a comparison of actual costs of the program 29 as administered prior to and after implementation of 30 Medicaid managed care. The data shall also include 31 specific detail regarding the actual expenses incurred 32 by each managed care organization by specific provider 33 line of service. 34 f. Review and approve or deny approval of contract 35 -45- SF2213.2830 (2) 86 pf/nh 45/ 48
amendments on an ongoing basis to provide for 1 continuous improvement in Medicaid managed care and 2 to incorporate any changes based on changes in law or 3 policy. 4 g. (1) Require managed care contractors to track 5 and report on a monthly basis to the department of 6 human services, at a minimum, all of the following: 7 (a) The number and details relating to prior 8 authorization requests and denials. 9 (b) The ten most common reasons for claims denials. 10 Information reported by a managed care contractor 11 relative to claims shall also include the number 12 of claims denied, appealed, and overturned based on 13 provider type and service type. 14 (c) Utilization of health care services by 15 diagnostic related group and ambulatory payment 16 classification as well as total claims volume. 17 (2) The department shall ensure the validity 18 of all information submitted by a Medicaid managed 19 care organization and shall make the monthly reports 20 available to the public. 21 h. Medicaid managed care organizations shall 22 maintain stakeholder panels comprised of an equal 23 number of Medicaid recipients and providers. Medicaid 24 managed care organizations shall provide for separate 25 provider-specific panels to address detailed payment, 26 claims, process, and other issues as well as grievance 27 and appeals processes. 28 i. Medicaid managed care contracts shall align 29 economic incentives, delivery system reforms, and 30 performance and outcome metrics with those of the state 31 innovation models initiatives and Medicaid accountable 32 care organizations. The department of human services 33 shall develop and utilize a common, uniform set of 34 process, quality, and consumer satisfaction measures 35 -46- SF2213.2830 (2) 86 pf/nh 46/ 48
across all Medicaid payors and providers that align 1 with those developed through the state innovation 2 models initiative and shall ensure that such measures 3 are expanded and adjusted to address additional 4 populations and to meet population health objectives. 5 Medicaid managed care contracts shall include long-term 6 performance and outcomes goals that reward success in 7 achieving population health goals such as improved 8 community health metrics. 9 j. (1) Require consistency and uniformity of 10 processes, procedures, and forms across all Medicaid 11 managed care organizations to reduce the administrative 12 burden to providers and consumers and to increase 13 efficiencies in the program. Such requirements shall 14 apply to but are not limited to areas of uniform cost 15 and quality reporting, uniform prior authorization 16 requirements and procedures, uniform utilization 17 management criteria, centralized, uniform, and seamless 18 credentialing requirements and procedures, and uniform 19 critical incident reporting. 20 (2) The department of human services shall 21 establish a comprehensive provider credentialing 22 process to be recognized and utilized by all Medicaid 23 managed care organization contractors. The process 24 shall meet the national committee for quality assurance 25 and other appropriate standards. The process shall 26 ensure that credentialing is completed in a timely 27 manner without disruption to provider billing 28 processes. 29 k. Medicaid managed care organizations and any 30 entity with which a managed care organization contracts 31 for the performance of services shall disclose at no 32 cost to the department all discounts, incentives, 33 rebates, fees, free goods, bundling arrangements, and 34 other agreements affecting the net cost of goods or 35 -47- SF2213.2830 (2) 86 pf/nh 47/ 48
services provided under a managed care contract. 1 Sec. 13. RETROACTIVE APPLICABILITY. The section of 2 this Act relating to directives for Medicaid program 3 policy improvements applies retroactively to July 1, 4 2015. 5 Sec. 14. EFFECTIVE UPON ENACTMENT. This Act, being 6 deemed of immediate importance, takes effect upon 7 enactment. > 8 ______________________________ AMANDA RAGAN ______________________________ LIZ MATHIS ______________________________ JOE BOLKCOM -48- SF2213.2830 (2) 86 pf/nh 48/ 48