House File 2356 H-8075 Amend House File 2356 as follows: 1 1. Page 5, after line 33 by inserting: 2 < Sec. ___. TERMINATION OF MEDICAID MANAGED CARE CONTRACTS 3 RELATIVE TO LONG-TERM SERVICES AND SUPPORTS POPULATION —— 4 TRANSITION TO FEE-FOR-SERVICE. The department of human 5 services shall, upon the effective date of this Act, provide 6 written notice in accordance with the termination provisions 7 of the contract, to each managed care organization with whom 8 the department executed a contract to administer the Iowa 9 high quality health care initiative as established by the 10 department, to terminate such contracts as applicable to 11 the Medicaid long-term services and supports population, 12 following a sixty-day transition period. The department shall 13 transfer the long-term services and supports population to 14 fee-for-service program administration. The transition shall 15 be based on a transition plan developed by the department and 16 submitted to the council on human services and the medical 17 assistance advisory council for review. 18 Sec. ___. INTEGRATED HEALTH HOME FOR PERSONS WITH SERIOUS 19 AND PERSISTENT MENTAL ILLNESS (SPMI INTEGRATED HEALTH 20 HOME). The department of human services shall adopt rules 21 pursuant to chapter 17A and shall amend existing Medicaid 22 managed care contracts to carve out SPMI integrated health 23 homes services as specified in the Medicaid state plan 24 amendment, IA-16-013, from Medicaid managed care contracts and 25 instead provide SPMI integrated health home services through 26 the fee-for-service payment and delivery system. 27 Sec. ___. RECALCULATION OF CERTAIN CAPITATION RATES 28 UNDER MEDICAID MANAGED CARE. For the fiscal year beginning 29 July 1, 2018, the department of human services shall utilize 30 Medicaid program claims paid data for the period beginning 31 April 1, 2015, and ending March 31, 2016, as base data to 32 develop and certify capitation rates for providers of home and 33 community-based intellectual disability waiver services under 34 Medicaid managed care. 35 -1- HF2356.3610 (4) 87 ko/rh 1/ 5 #1.

Sec. ___. MEDICAID MANAGED CARE OVERSIGHT. The department 1 of human services shall amend the Medicaid managed care 2 contracts and adopt rules pursuant to chapter 17A to provide 3 that beginning July 1, 2018, all of the following shall apply: 4 1. MEMBER STATUS CHANGES. 5 a. A Medicaid managed care organization shall provide prior 6 notice, in writing, to a member and to any affected provider, 7 of any change in the status of the member at least thirty 8 days prior to the effective date of the change in status. If 9 notification is not received by the provider and the member 10 continues to receive services from the provider, the Medicaid 11 managed care organization shall reimburse the provider for 12 services rendered. 13 b. If a member transfers from one managed care organization 14 to another, the managed care organization from which the 15 member is transferring shall forward the member’s records to 16 the managed care organization assuming the member’s coverage 17 at least thirty days prior to the managed care organization 18 assuming such coverage. 19 c. If a provider provides services to a member for which the 20 member is eligible while awaiting any necessary authorization, 21 and the authorization is subsequently approved, the provider 22 shall be reimbursed at the contracted rate for any services 23 provided prior to receipt of the authorization. 24 2. DATA. Managed care organizations shall report to the 25 department of human services not only the percentage of medical 26 and pharmacy clean claims paid or denied within a certain 27 time frame, but shall also report all of the following on a 28 quarterly basis: 29 a. The total number of original medical and pharmacy claims 30 submitted to the managed care organization. 31 b. The total number of original medical and pharmacy claims 32 deemed rejected and the reason for rejection. 33 c. The total number of original medical and pharmacy claims 34 deemed suspended, the reason for suspension, and the number of 35 -2- HF2356.3610 (4) 87 ko/rh 2/ 5

days from suspension to submission for processing. 1 d. The total number of original medical and pharmacy 2 claims initially deemed either rejected or suspended that are 3 subsequently deemed clean claims and paid, and the average 4 number of days from initial submission to payment of the clean 5 claim. 6 e. The total number of medical and pharmacy claims that 7 are outstanding for thirty, sixty, ninety, one hundred eighty, 8 or more than one hundred eighty days, and the total amount 9 attributable to these outstanding claims if paid as submitted. 10 f. The total amount requested as payment for all original 11 medical or pharmacy claims versus the total amount actually 12 paid as clean claims and the total amount of payment denied. 13 g. The total number of original medical and pharmacy claims 14 received, the number of such claims for which one hundred 15 percent of the requested amount was paid, the number of such 16 claims for which less than one hundred percent of the requested 17 amount was paid and the percentage actually paid, and the total 18 dollar amount of payments denied. 19 3. REIMBURSEMENT. For the fiscal year beginning July 1, 20 2018, Medicaid providers or services shall be reimbursed as 21 follows: 22 a. For fee-for-service claims, reimbursement shall be 23 calculated based on the methodology in effect on June 30, 2018, 24 for the respective provider or service. 25 b. For claims subject to a managed care contract: 26 (1) Reimbursement shall be based on the methodology 27 established by the managed care contract. However, any 28 reimbursement established under such contract shall not be 29 lower than the rate floor established by the department of 30 human services as the managed care organization provider or 31 service reimbursement rate floor for the respective provider or 32 service in effect on June 30, 2018. 33 (2) For any provider or service to which a reimbursement 34 increase is applicable for the fiscal year under state law, 35 -3- HF2356.3610 (4) 87 ko/rh 3/ 5

upon the effective date of the reimbursement increase, the 1 department of human services shall modify the rate floor in 2 effect on June 30, 2018, to reflect the increase specified. 3 Any reimbursement established under the managed care contract 4 shall not be lower than the rate floor as modified by the 5 department of human services to reflect the provider rate 6 increase specified. 7 (3) Any reimbursement established between the managed 8 care organization and the provider shall be in effect for at 9 least twelve months from the date established, unless the 10 reimbursement is increased. A reimbursement rate that is 11 negotiated and established above the rate floor shall not be 12 decreased from that amount for at least twelve months from the 13 date established. 14 4. PRIOR AUTHORIZATION. 15 a. Any change by a Medicaid managed care organization in a 16 requirement for prior authorization for a prescription drug or 17 service shall be preceded by the provision of sixty days’ prior 18 written notice published on the managed care organization’s 19 internet site and provided in writing to all affected members 20 and providers before the effective date of the change. 21 b. Each managed care organization shall post to the managed 22 care organization’s internet site prior authorization data 23 including but not limited to statistics on approvals and 24 denials of prior authorization requests by physician specialty, 25 medication, test, procedure, or service, the indication 26 offered, and if denied, the reason for denial. 27 Sec. ___. MEDICAID STATE PLAN OR WAIVER AMENDMENTS. The 28 department of human services shall seek any Medicaid state plan 29 or waiver amendments necessary to administer this Act. 30 Sec. ___. EFFECTIVE DATE. The following, being deemed of 31 immediate importance, take effect upon enactment. 32 1. The section of this Act related to termination of 33 Medicaid managed care contracts relative to long-term services 34 and supports populations. 35 -4- HF2356.3610 (4) 87 ko/rh 4/ 5

2. The section of this Act related to SPMI integrated health 1 home services. 2 3. The section of this Act related to the recalculation of 3 certain capitation rates under Medicaid managed care. 4 4. The section of this Act related to Medicaid managed care 5 oversight. 6 5. The section of this Act related to Medicaid state plan 7 or waiver amendments. > 8 2. Title page, by striking lines 1 through 4 and inserting 9 < An Act relating to the provision of certain health care 10 services, including through agreements between individuals and 11 health care professionals for the provision of certain primary 12 care health services, and including through the Medicaid 13 program, and including effective date provisions. > 14 3. By renumbering as necessary. 15 ______________________________ HEDDENS of Story ______________________________ ANDERSON of Polk -5- HF2356.3610 (4) 87 ko/rh 5/ 5 #2. #3.