House File 653 H-1407 Amend the amendment, H-1399, to House File 653, as follows: 1 1. Page 5, after line 33 by inserting: 2 < DIVISION ___ 3 BENEFITS COVERED UNDER HEALTH AND WELLNESS PLAN 4 Sec. ___. Section 249A.3, subsection 1, paragraph v, 5 subparagraph (2), Code 2017, is amended to read as follows: 6 (2) Notwithstanding any provision to the contrary, 7 individuals eligible for medical assistance under this 8 paragraph “v” shall receive coverage for benefits pursuant to 9 42 U.S.C. §1396u-7(b)(1)(B); adjusted as necessary to provide 10 the essential health benefits as required pursuant to section 11 1302 of the federal Patient Protection and Affordable Care Act, 12 Pub. L. No. 111-148; adjusted to provide prescription drugs 13 and dental services consistent with the medical assistance 14 state plan benefits package for individuals otherwise eligible 15 under this subsection; and adjusted to provide habilitation 16 services consistent with the state medical assistance program 17 section 1915(i) waiver. Beginning July 1, 2017, coverage for 18 benefits shall also include coverage for integrated health home 19 services, residential substance abuse treatment, assertive 20 community treatment, nonemergency medical transportation, and 21 peer support. 22 Sec. ___. DIRECTIVE TO DEPARTMENT OF HUMAN SERVICES. Upon 23 enactment of this division of this Act, the department of human 24 services shall request federal approval of an amendment to the 25 medical assistance state plan, as necessary, to implement this 26 division of this Act effective July 1, 2017. 27 Sec. ___. EFFECTIVE UPON ENACTMENT AND CONTINGENT 28 IMPLEMENTATION. This division of this Act, being deemed of 29 immediate importance, takes effect upon enactment. However, 30 the department of human services shall implement this division, 31 effective July 1, 2017, contingent upon receipt of federal 32 approval of the state plan amendment request submitted under 33 this division of this Act. The director of human services 34 shall notify the Code editor of the receipt of approval and the 35 -1- H1399.2522 (3) 87 pf/rn 1/ 7 #1.

date of implementation. 1 DIVISION ___ 2 MEDICAID MANAGED CARE QUALITY IMPROVEMENT 3 Sec. ___. MEDICAID MANAGED CARE CHANGES. The department of 4 human services shall adopt rules pursuant to chapter 17A and 5 shall amend any Medicaid managed care contract effective July 6 1, 2017, to provide for all of the following: 7 1. PRIMARY CARE PROVIDERS 8 a. A Medicaid managed care organization shall include as a 9 primary care provider any provider designated by the state as a 10 primary care provider, subject to a provider’s respective state 11 certification standards, including but not limited to all of 12 the following: 13 (1) A physician who is a family or general practitioner, a 14 pediatrician, an internist, an obstetrician, or a gynecologist. 15 (2) An advanced registered nurse practitioner. 16 (3) A physician assistant. 17 (4) A chiropractor. 18 b. A Medicaid managed care organization shall not impose 19 more restrictive scope-of-practice requirements or standards of 20 practice on a primary care provider than those prescribed by 21 state law as a prerequisite for participation in the managed 22 care organization’s provider network. 23 2. CASE MANAGEMENT 24 a. A Medicaid managed care organization shall provide 25 the option to the case manager for a Medicaid member, if the 26 case manager is not otherwise a participating provider in 27 the member’s managed care organization provider network, to 28 enter into a single case agreement to continue to provide case 29 management services to the Medicaid member at the member’s 30 request. 31 b. A Medicaid managed care organization shall allow peer 32 support specialists to serve as case managers for members 33 receiving behavioral health services, and shall not require 34 that such peer support specialists hold a bachelor’s degree 35 -2- H1399.2522 (3) 87 pf/rn 2/ 7

from an accredited school, college, or university. 1 3. MEMBER STATUS CHANGES 2 a. A Medicaid managed care organization shall provide prior 3 notice to a provider of a member of any change in the status 4 of the member that affects such provider at least fourteen 5 days prior to the effective date of the change in status. If 6 notification is not received by the provider and the member 7 continues to receive services from the provider, the Medicaid 8 managed care organization shall reimburse the provider for 9 services rendered. 10 b. If a member transfers from one managed care organization 11 to another, the managed care organization from which the 12 member is transferring shall forward the member’s records to 13 the managed care organization assuming the member’s coverage 14 at least thirty days prior to the managed care organization 15 assuming such coverage. 16 c. If a provider provides services to a member for which the 17 member is eligible while awaiting any necessary authorization, 18 and the authorization is subsequently approved, the provider 19 shall be reimbursed at the contracted rate for any services 20 provided prior to receipt of the authorization. 21 4. UNIFORMITY OF PROGRAM 22 a. The department of human services shall work with the 23 Medicaid managed care organizations to institute consistency 24 and uniformity across processes and procedures, including 25 but not limited to those related to claims filing and denial 26 of claims, integrated health home criteria, and appeals and 27 grievances. 28 b. The department shall require the use and application of 29 the following definition of medically necessary services across 30 all Medicaid managed care organizations: 31 “Medically necessary services” means those services that 32 a prudent health care provider would provide to prevent, 33 diagnose, or treat an illness, injury, disease, or symptoms of 34 an illness, injury, or disease in a manner that meets all of 35 -3- H1399.2522 (3) 87 pf/rn 3/ 7

the following requirements: 1 (1) The services are in accordance with generally accepted 2 standards of medical practice. 3 (2) The services are clinically appropriate in terms of 4 type, frequency, extent, site, and duration. 5 (3) The services are not primarily for the economic benefit 6 of the managed care organization or health care provider or for 7 the convenience of the member or health care provider. 8 5. OVERSIGHT. The department shall require completion of an 9 initial external quality review of the Medicaid managed care 10 program by January 1, 2018. Additionally, the department shall 11 contract with the university of Iowa public policy center to 12 perform an evaluation of the program by January 1, 2018. 13 6. DATA. The department shall amend the requirements for 14 quarterly reports to require that managed care organizations 15 report not only the percentage of medical and pharmacy clean 16 claims paid or denied within a certain time frame but also all 17 of the following: 18 a. The total number of original medical and pharmacy claims 19 submitted to the managed care organization during the time 20 period. 21 b. The total number of original medical and pharmacy claims 22 deemed rejected and the reason for rejection. 23 c. The total number of original medical and pharmacy claims 24 deemed suspended, the reason for suspension, and the number of 25 days from suspension to submission for processing. 26 d. The total number of original medical and pharmacy 27 claims initially deemed either rejected or suspended that are 28 subsequently deemed clean claims and paid, and the average 29 number of days from initial submission to payment of the clean 30 claim. 31 e. The total number of medical and pharmacy claims that 32 are outstanding for thirty, sixty, ninety, one hundred eighty, 33 or more than one hundred eighty days, and the total amount 34 attributable to these outstanding claims if paid as submitted. 35 -4- H1399.2522 (3) 87 pf/rn 4/ 7

f. The total amount requested as payment for all original 1 medical or pharmacy claims versus the total actual amount paid 2 as clean claims and the total amount of payment denied. 3 7. REIMBURSEMENT. For the fiscal year beginning July 1, 4 2017, Medicaid providers or services shall be reimbursed as 5 follows: 6 a. For fee-for-service claims, reimbursement shall be 7 calculated based on the methodology in effect on June 30, 2017, 8 for the respective provider or service. 9 b. For claims subject to a managed care contract: 10 (1) Reimbursement shall be based on the methodology 11 established by the managed care contract. However, any 12 reimbursement established under such contract shall not be 13 lower than the rate floor established by the department of 14 human services as the managed care organization provider or 15 service reimbursement rate floor for the respective provider or 16 service in effect on April 1, 2016. 17 (2) For any provider or service to which a reimbursement 18 increase is applicable for the fiscal year under state law, 19 upon the effective date of the reimbursement increase, the 20 department of human services shall modify the rate floor in 21 effect on April 1, 2016, to reflect the increase specified. 22 Any reimbursement established under the managed care contract 23 shall not be lower than the rate floor as modified by the 24 department of human services to reflect the provider rate 25 increase specified. 26 (3) Any reimbursement established between the managed 27 care organization and the provider shall be in effect for at 28 least twelve months from the date established, unless the 29 reimbursement is increased. A reimbursement rate that is 30 negotiated and established above the rate floor shall not be 31 decreased from that amount for at least twelve months from the 32 date established. 33 8. PRIOR AUTHORIZATION 34 a. A Medicaid managed care organization shall approve or 35 -5- H1399.2522 (3) 87 pf/rn 5/ 7

deny a prior authorization request submitted by a provider for 1 a prescription drug or service within the following periods, 2 as applicable: 3 (1) For urgent claims, within a period not to exceed 4 forty-eight hours from the time the Medicaid managed care 5 organization receives the request. 6 (2) For nonurgent claims, within a period not to exceed 7 five calendar days from the time the Medicaid managed care 8 organization receives the request. 9 b. Emergency claims for prescription drugs or services 10 shall not require prior authorization by a Medicaid managed 11 care organization. Prior authorization shall not be required 12 for prehospital transportation and emergency services, and 13 coverage shall be provided for emergency services necessary 14 to screen and stabilize a member. A provider that submits 15 written certification to the managed care organization within 16 seventy-two hours of admission of a member who was admitted 17 to a hospital through the emergency department shall create 18 a presumption that the emergency services were medically 19 necessary for purposes of coverage. 20 c. If a Medicaid managed care organization approves a 21 provider’s prior authorization request for a prescription drug 22 or service for a patient who is in stable condition as verified 23 by the provider, the prior authorization shall be valid for a 24 period of twelve months from the date the approval is received 25 by the provider. 26 d. If a Medicaid managed care organization approves a 27 provider’s prior authorization request for a prescription 28 drug or service, the managed care organization shall not 29 retroactively revoke, limit, condition, or restrict the prior 30 authorization after the prescription drug is dispensed or the 31 service is provided. 32 e. Any change by a Medicaid managed care organization in a 33 requirement for prior authorization for a prescription drug or 34 service shall be preceded by the provision of sixty days’ prior 35 -6- H1399.2522 (3) 87 pf/rn 6/ 7

notice published on the managed care organization’s internet 1 site and to all affected providers before the effective date 2 of the change. 3 f. Each managed care organization shall post to the managed 4 care organization’s internet site prior authorization data 5 including but not limited to statistics on approvals and 6 denials of prior authorization requests by physician specialty, 7 medication, test, procedure, or service, the indication 8 offered, and if denied, the reason for denial. 9 g. The department of human services shall require any 10 Medicaid managed care organization under contract with 11 the state to jointly develop and utilize the same prior 12 authorization review process, including but not limited to 13 shared electronic and paper forms, subject to final review and 14 approval by the department. 15 Sec. ___. EFFECTIVE UPON ENACTMENT. This division of this 16 Act, being deemed of immediate importance, takes effect upon 17 enactment. > 18 2. By renumbering as necessary. 19 ______________________________ WINCKLER of Scott -7- H1399.2522 (3) 87 pf/rn 7/ 7 #2.