Senate File 2421 S-5060 Amend Senate File 2421 as follows: 1 1. By striking everything after the enacting clause and 2 inserting: 3 < DIVISION I 4 HEALTH INSURANCE TRADE PRACTICES 5 Section 1. Section 514F.8, Code 2026, is amended by adding 6 the following new subsection: 7 NEW SUBSECTION . 2A. A utilization review organization may 8 use an artificial intelligence-based algorithm or system to 9 provide an initial review of a request for prior authorization, 10 except that, for a prior authorization request for a health 11 care service based on medical necessity, a utilization review 12 organization shall not use an artificial intelligence-based 13 algorithm or system as the sole basis for the utilization 14 review organization’s decision to deny, delay, or downgrade the 15 prior authorization request. 16 Sec. 2. NEW SECTION . 514F.8C Utilization review 17 organizations —— audits. 18 1. As used in this section, unless the context otherwise 19 requires: 20 a. “Audit” means a review, investigation, or request for 21 additional documentation by a utilization review organization 22 before or after issuing payment on a claim to a health care 23 provider. 24 b. “Commissioner” means the commissioner of insurance. 25 c. “Health care provider” means the same as defined in 26 section 514F.8. 27 d. “Health carrier” means the same as defined in Section 28 514F.8. 29 e. “Utilization review organization” means the same as 30 defined in section 514F.8. 31 2. a. A utilization review organization that conducts an 32 audit shall notify the health care provider that submitted 33 the claim of the initiation of the audit no later than 34 fifteen calendar days after the date the utilization review 35 -1- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 1/ 21 #1.

organization selects the claim for audit. 1 b. A utilization review organization shall complete an audit 2 of a claim and issue a determination on the claim to the health 3 care provider that submitted the claim no later than forty-five 4 calendar days after the date that the utilization review 5 organization receives all requested documentation regarding the 6 claim from the health care provider. 7 c. A health care provider that submitted a claim that is 8 the subject of an audit by a utilization review organization 9 that receives an adverse determination regarding the claim may 10 appeal the adverse determination no later than thirty calendar 11 days after the date the health care provider receives the audit 12 determination. 13 d. A utilization review organization shall consider an 14 appeal under paragraph “c” and issue a final determination 15 on the claim that is the subject of the appeal no later than 16 thirty calendar days after the date the utilization review 17 organization receives notice of the appeal. 18 e. If, after a hearing, the commissioner finds that a 19 utilization review organization has violated this subsection, 20 the claim shall be approved by the utilization review 21 organization and promptly paid, including interest at the rate 22 of ten percent per annum. 23 3. a. This section applies to the following classes of 24 third-party payment provider contracts, policies, or plans 25 delivered, issued for delivery, continued, or renewed in this 26 state on or after January 1, 2027: 27 (1) Individual or group accident and sickness insurance 28 providing coverage on an expense-incurred basis. 29 (2) An individual or group hospital or medical service 30 contract issued pursuant to chapter 509, 514, or 514A. 31 (3) An individual or group health maintenance organization 32 contract regulated under chapter 514B. 33 (4) A plan established for public employees pursuant to 34 chapter 509A. 35 -2- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 2/ 21

b. This section shall not apply to accident-only, specified 1 disease, short-term hospital or medical, hospital confinement 2 indemnity, credit, dental, vision, Medicare supplement, 3 long-term care, basic hospital and medical-surgical expense 4 coverage as defined by the commissioner of insurance, 5 disability income insurance coverage, coverage issued as a 6 supplement to liability insurance, workers’ compensation or 7 similar insurance, or automobile medical payment insurance. 8 4. The commissioner may adopt rules pursuant to chapter 17A 9 to administer and enforce this section. 10 5. a. This section shall apply to an audit initiated on or 11 after January 1, 2027. 12 b. This section shall not apply to a claim that is under 13 active fraud investigation by a state or federal authority. 14 c. This section shall not apply to a federal program where 15 audits are mandated by federal law. 16 Sec. 3. NEW SECTION . 514F.8D Health carriers —— standards 17 of conduct. 18 1. As used in this section, unless the context otherwise 19 requires: 20 a. “Health care provider” means the same as defined in 21 section 514J.102. 22 b. “Health carrier” means the same as defined in section 23 514F.8. 24 2. A health carrier shall not impose on a health care 25 provider, directly or indirectly, any financial penalty, 26 reimbursement reduction, or administrative fee, or terminate a 27 health care provider’s participation in the health carrier’s 28 network, based on the health care provider’s referral to, or 29 affiliation with, an out-of-network health care provider. 30 3. A health carrier shall not interfere with, or participate 31 in any capacity in, a health care provider’s decisions 32 regarding staffing and referrals, except as otherwise provided 33 by law. 34 4. A health carrier shall not offer, attempt to enforce, 35 -3- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 3/ 21

or enforce an agreement, or an amendment to an agreement, with 1 a health care provider without providing an opportunity for 2 negotiation. 3 5. The commissioner may adopt rules pursuant to chapter 17A 4 to administer and enforce this section. 5 DIVISION II 6 PRIOR AUTHORIZATIONS 7 Sec. 4. NEW SECTION . 514F.8A Prior authorizations —— peer 8 review. 9 1. For purposes of this section, unless the context 10 otherwise requires: 11 a. “Clinical peer” means a health care professional that 12 meets all of the following requirements: 13 (1) The health care professional practices in the same or 14 similar specialty as the health care provider that requested 15 a prior authorization. 16 (2) The health care professional has experience managing 17 the specific medical condition or administering the health care 18 service that is the subject of the prior authorization request. 19 (3) The health care professional is employed by or 20 contracted with the utilization review organization or health 21 carrier to which a health care provider submitted a request for 22 prior authorization. 23 b. “Covered person” means the same as defined in section 24 514F.8. 25 c. “Downgrade” means a decision by a utilization review 26 organization to change an expedited or urgent request for prior 27 authorization to a standard determination, or otherwise modify 28 a health care service that is the subject of a request for 29 prior authorization to a lower-level health care service. 30 d. “Health care professional” means the same as defined in 31 section 514J.102. 32 e. “Health care provider” means the same as defined in 33 section 514F.8. 34 f. “Health care services” means the same as defined in 35 -4- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 4/ 21

section 514F.8. 1 g. “Health carrier” means the same as defined in section 2 514F.8. 3 h. “Physician” means a doctor of medicine and surgery, or 4 a doctor of osteopathic medicine and surgery, licensed under 5 chapter 148. 6 i. “Prior authorization” means the same as defined in 7 section 514F.8. 8 j. “Qualified reviewer” means a physician that meets all of 9 the following requirements: 10 (1) The physician practices in the same or a similar 11 specialty as the health care provider that requested a prior 12 authorization. 13 (2) The physician has the training and expertise to treat 14 the specific medical condition that is the subject of a 15 request for prior authorization, including sufficient knowledge 16 to determine whether the health care service that is the 17 subject of the request is medically necessary or clinically 18 appropriate. 19 (3) The physician is employed by or contracted with the 20 utilization review organization to which a health care provider 21 submitted a request for prior authorization. 22 k. “Utilization review organization” means the same as 23 defined in section 514F.8. 24 2. A utilization review organization shall not deny or 25 downgrade a request for prior authorization unless all of the 26 following requirements are met: 27 a. The decision to deny or downgrade the request is made by 28 either of the following: 29 (1) A qualified reviewer, if the health care provider 30 requesting prior authorization is a physician. 31 (2) A clinical peer, if the health care provider requesting 32 prior authorization is not a physician. 33 b. The utilization review organization provides the health 34 care provider that requested the prior authorization all of the 35 -5- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 5/ 21

following: 1 (1) A written statement that cites the specific reasons 2 for the denial or downgrade, including any coverage criteria 3 or limits, or clinical criteria, that the utilization review 4 organization considered or that was the basis for the denial 5 or downgrade. The written statement must be signed by either 6 of the following: 7 (a) The qualified reviewer that made the denial or downgrade 8 determination if the health care provider that requested prior 9 authorization is a physician. 10 (b) The clinical peer that made the denial or downgrade 11 determination if the health care provider that requested prior 12 authorization is not a physician. 13 (2) A written explanation of the utilization review 14 organization’s appeals process. The utilization review 15 organization shall also provide the written explanation to the 16 covered person for whom prior authorization was requested. 17 (3) A written attestation that is either of the following: 18 (a) If the health care provider that requested prior 19 authorization is a physician, a written attestation that 20 the qualified reviewer who made the denial or downgrade 21 determination practices in the same or a similar specialty as 22 the health care provider, and has the requisite training and 23 expertise to treat the medical condition that is the subject 24 of the request for prior authorization, including sufficient 25 knowledge to determine whether the health care service is 26 medically necessary or clinically appropriate. The attestation 27 shall include the qualified reviewer’s name, national provider 28 identifier, state medical license number, board certifications, 29 specialty expertise, and educational background. 30 (b) If the health care provider that requested prior 31 authorization is not a physician, a written attestation 32 that the clinical peer who made the denial or downgrade 33 determination practices in the same or a similar specialty as 34 the health care provider, and the clinical peer has experience 35 -6- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 6/ 21

managing the specific medical condition or administering 1 the health care service that is the subject of the request 2 for prior authorization. The attestation shall include the 3 clinical peer’s name, national provider identifier, state 4 medical license number, board certifications, specialty 5 expertise, and educational background. 6 3. At the request of the requesting health care provider, a 7 utilization review organization that denies a request for prior 8 authorization shall, no later than seven business days after 9 the date that the utilization review organization notifies 10 the requesting health care provider of the denial, conduct a 11 consultation either in person or remotely, as follows: 12 a. Between the health care provider and a qualified reviewer 13 if the health care provider requesting prior authorization is a 14 physician. 15 b. Between the health care provider and a clinical peer if 16 the health care provider requesting prior authorization is not 17 a physician. 18 4. a. If a utilization review organization’s decision to 19 deny or downgrade a request for prior authorization is appealed 20 by the requesting health care provider or covered person, the 21 appeal shall be conducted by either of the following: 22 (1) A qualified reviewer if the health care provider 23 requesting prior authorization is a physician. 24 (2) A clinical peer if the health care provider requesting 25 prior authorization is not a physician. 26 b. A qualified reviewer or clinical peer involved in the 27 initial denial or downgrade determination of a request for 28 prior authorization that is the subject of an appeal shall not 29 conduct the appeal. 30 c. When conducting an appeal of a request for prior 31 authorization, the qualified reviewer or clinical peer shall 32 consider the known clinical aspects of the health care services 33 under review, including but not limited to medical records 34 relevant to the covered person’s medical condition who is 35 -7- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 7/ 21

the subject of the health care services for which prior 1 authorization is requested, and any relevant medical literature 2 submitted by the health care provider as part of the appeal. 3 5. This section applies to requests for prior authorization 4 made on or after January 1, 2027. 5 6. a. This section applies to the following classes of 6 third-party payment provider contracts, policies, or plans 7 delivered, issued for delivery, continued, or renewed in this 8 state on or after January 1, 2027: 9 (1) Individual or group accident and sickness insurance 10 providing coverage on an expense-incurred basis. 11 (2) An individual or group hospital or medical service 12 contract issued pursuant to chapter 509, 514, or 514A. 13 (3) An individual or group health maintenance organization 14 contract regulated under chapter 514B. 15 (4) A plan established for public employees pursuant to 16 chapter 509A. 17 b. This section shall not apply to accident-only, specified 18 disease, short-term hospital or medical, hospital confinement 19 indemnity, credit, dental, vision, Medicare supplement, 20 long-term care, basic hospital and medical-surgical expense 21 coverage as defined by the commissioner of insurance, 22 disability income insurance coverage, coverage issued as a 23 supplement to liability insurance, workers’ compensation or 24 similar insurance, or automobile medical payment insurance. 25 7. The commissioner of insurance may adopt rules pursuant to 26 chapter 17A to administer this section. 27 Sec. 5. NEW SECTION . 514F.8B Prior authorizations —— 28 exemptions. 29 1. For purposes of this section: 30 a. “Covered person” means the same as defined in section 31 514F.8. 32 b. “Health benefit plan” means the same as defined in 33 section 514J.102. 34 c. “Health care professional” means the same as defined in 35 -8- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 8/ 21

section 514J.102. 1 d. “Health carrier” means the same as defined in section 2 514F.8. 3 e. “Prior authorization” means the same as defined in 4 section 514F.8. 5 f. “Utilization review” means the same as defined in section 6 514F.4, subsection 3. 7 2. A health carrier shall not require prior authorization 8 for, or impose additional utilization review requirements on, a 9 covered person for any of the following: 10 a. A cancer-related screening if the cancer-related 11 screening is recommended by the covered person’s health care 12 professional based on the most recently updated national 13 comprehensive cancer network clinical practice guidelines in 14 oncology which are designated as category 2A or lower. 15 b. Diagnosis and treatment of an emergency medical condition 16 that develops or becomes evident in a covered person while 17 the covered person is receiving inpatient care that meets 18 inpatient care standards, if the emergency medical condition 19 is reasonably determined by a health care professional to be a 20 life-threatening condition unless the covered person receives 21 immediate assessment and treatment. 22 3. This section applies to all of the following: 23 a. Health benefit plans delivered, issued for delivery, 24 continued, or renewed in this state on or after January 1, 25 2027. 26 b. Requests for prior authorization for a cancer-related 27 screening, if the screening is recommended by the covered 28 person’s health care professional based on the most recently 29 updated national comprehensive cancer network clinical practice 30 guidelines in oncology designated as category 2A or lower, and 31 is made on or after January 1, 2027. 32 c. Requests for prior authorization for the diagnosis and 33 treatment of an emergency medical condition that develops or 34 becomes evident in a covered person while the covered person is 35 -9- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 9/ 21

receiving inpatient care that meets inpatient care standards, 1 if the emergency medical condition is reasonably determined by 2 a health care professional to be a life-threatening condition 3 unless the covered person receives immediate assessment and 4 treatment if the request is made on or after January 1, 2027. 5 4. a. This section applies to the following classes of 6 third-party payment provider contracts, policies, or plans 7 delivered, issued for delivery, continued, or renewed in this 8 state on or after January 1, 2027: 9 (1) Individual or group accident and sickness insurance 10 providing coverage on an expense-incurred basis. 11 (2) An individual or group hospital or medical service 12 contract issued pursuant to chapter 509, 514, or 514A. 13 (3) An individual or group health maintenance organization 14 contract regulated under chapter 514B. 15 (4) A plan established for public employees pursuant to 16 chapter 509A. 17 b. This section shall not apply to accident-only, specified 18 disease, short-term hospital or medical, hospital confinement 19 indemnity, credit, dental, vision, Medicare supplement, 20 long-term care, basic hospital and medical-surgical expense 21 coverage as defined by the commissioner of insurance, 22 disability income insurance coverage, coverage issued as a 23 supplement to liability insurance, workers’ compensation or 24 similar insurance, or automobile medical payment insurance. 25 5. The commissioner of insurance may adopt rules pursuant to 26 chapter 17A to administer this section. 27 Sec. 6. NEW SECTION . 514F.8E Enforcement. 28 The remedy for noncompliance with section 514F.8, 514F.8A, 29 514F.8B, 514F.8C, or 514F.8D shall be those remedies authorized 30 by chapters 505 and 507B pursuant to the procedures set forth 31 in sections 507B.6, 507B.7, and 507B.8. Upon a finding of 32 a pattern or practice of noncompliance with sections 514F.8, 33 514F.8A, 514F.8B, 514F.8C, or 514F.8D, the commissioner of 34 insurance may also suspend a utilization review organization’s 35 -10- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 10/ 21

authority to conduct utilization review. 1 DIVISION III 2 PRIOR AUTHORIZATIONS —— MEDICAL ASSISTANCE PROGRAM 3 Sec. 7. NEW SECTION . 249A.5 Prior authorization —— 4 exemptions. 5 1. For purposes of this section, unless the context 6 otherwise requires: 7 a. “Emergency medical condition” means the same as defined 8 in 42 C.F.R. §438.114. 9 b. “Managed care organization” means an entity acting 10 pursuant to a contract with the department to administer the 11 medical assistance program. 12 c. “Prior authorization” means any process used by the 13 department or a managed care organization to determine if, 14 before a health care service is furnished to a recipient, the 15 service is covered or medically necessary. 16 d. “Utilization review” means a set of formal techniques 17 used to monitor or evaluate the medical necessity, 18 appropriateness, or efficiency of a health care service. 19 2. The department, or a managed care organization, shall 20 not require prior authorization for, or impose additional 21 utilization review requirements on, a recipient for any of the 22 following: 23 a. A cancer-related screening recommended for the recipient 24 by the recipient’s provider in accordance with the most 25 recently updated national comprehensive cancer network clinical 26 practice guidelines in oncology which are designated as 27 category 2A or lower. 28 b. The diagnosis and treatment of an emergency medical 29 condition that develops or becomes evident in a recipient 30 while the recipient is receiving inpatient care that 31 meets inpatient care standards, if the emergency medical 32 condition is reasonably determined by a provider to present a 33 life-threatening risk unless the recipient receives immediate 34 assessment and treatment. 35 -11- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 11/ 21

3. This section applies to all of the following: 1 a. All contracts between the department and a managed 2 care organization that are delivered, issued for delivery, 3 continued, extended, or renewed on or after January 1, 2027. 4 b. All requests for prior authorization made on or after 5 January 1, 2027. 6 4. The department may adopt rules pursuant to chapter 17A to 7 administer this section. 8 Sec. 8. NEW SECTION . 514I.13 Prior authorizations —— 9 exemptions. 10 1. For purposes of this section: 11 a. “Emergency medical condition” means the same as defined 12 in 42 C.F.R. §438.114. 13 b. “Health care professional” means a person licensed or 14 certified under the laws of this state to provide health care 15 services to an eligible child. 16 c. “Managed care organization” means an entity acting 17 pursuant to a contract with the department to administer the 18 Hawki program. 19 d. “Prior authorization” means any process used by the 20 department or a managed care organization to determine if, 21 before a health care service is furnished to an eligible child, 22 the service is covered or medically necessary. 23 e. “Utilization review” means a set of formal techniques 24 used to monitor or evaluate the medical necessity, 25 appropriateness, or efficiency of a health care service. 26 2. The department, or a managed care organization, shall 27 not require prior authorization for, or impose additional 28 utilization review requirements on, an eligible child for any 29 of the following: 30 a. A cancer-related screening recommended for the eligible 31 child by the eligible child’s health care professional 32 in accordance with the most recently updated national 33 comprehensive cancer network clinical practice guidelines in 34 oncology which are designated as category 2A or lower. 35 -12- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 12/ 21

b. The diagnosis and treatment of an emergency medical 1 condition that develops or becomes evident in an eligible child 2 while the eligible child is receiving inpatient care that meets 3 inpatient care standards, if the emergency medical condition is 4 reasonably determined by a health care professional to present 5 a life-threatening risk unless the eligible child receives 6 immediate assessment and treatment. 7 3. This section applies to all of the following: 8 a. All contracts between the department and a managed 9 care organization that are delivered, issued for delivery, 10 continued, extended, or renewed on or after January 1, 2027. 11 b. All requests for prior authorizations made on or after 12 January 1, 2027. 13 4. The department may adopt rules pursuant to chapter 17A to 14 administer this section. 15 DIVISION IV 16 CERTIFICATES OF NEED 17 Sec. 9. Section 135.61, subsection 1, paragraphs d and f, 18 Code 2026, are amended by striking the paragraphs. 19 Sec. 10. Section 135.61, subsection 12, paragraph e, Code 20 2026, is amended by striking the paragraph. 21 Sec. 11. Section 135.61, subsection 16, Code 2026, is 22 amended to read as follows: 23 16. “New institutional health service” or “changed 24 institutional health service” means any of the following: 25 a. (1) The construction, development , or other 26 establishment of a new institutional health facility regardless 27 of ownership if completing the construction, development, or 28 other establishment requires more than the following amount: 29 (a) Beginning on or after January 1, 2027, and before 30 December 31, 2031, four million dollars . 31 (b) Beginning on or after January 1, 2032, and before 32 December 31, 2036, four million five hundred thousand dollars. 33 (c) Beginning on or after January 1, 2037, five million 34 dollars. 35 -13- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 13/ 21

(2) If the new institutional health facility involves 1 the use of a leased building, the market value of the leased 2 building shall be used when calculating the value of completing 3 construction, development, or other establishment under 4 subparagraph (1). 5 b. Relocation of an institutional health facility. 6 c. Any A capital expenditure, lease, or donation by or on 7 behalf of an institutional health facility in excess of one 8 million five hundred thousand dollars the following amount 9 within a consecutive twelve-month period : 10 (1) Beginning on or after January 1, 2027, and before 11 December 31, 2031, four million dollars. 12 (2) Beginning on or after January 1, 2032, and before 13 December 31, 2036, four million five hundred thousand dollars. 14 (3) Beginning on or after January 1, 2037, five million 15 dollars . 16 d. A permanent change in the bed capacity, as determined 17 by the department, of an institutional health facility. For 18 purposes of this paragraph, a change is permanent if it is 19 intended to be effective for one year or more. 20 e. Any expenditure in excess of five hundred thousand 21 dollars by or on behalf of an institutional health facility for 22 health services which are or will be offered in or through an 23 institutional health facility at a specific time but which were 24 not offered on a regular basis in or through that institutional 25 health facility within the twelve-month period prior to that 26 time. 27 f. The deletion of one or more health services, previously 28 offered on a regular basis by an institutional health facility 29 or health maintenance organization or the relocation of one or 30 more health services from one physical facility to another. 31 g. Any acquisition by or on behalf of a health care provider 32 or a group of health care providers of any piece of replacement 33 equipment with a value in excess of one million five hundred 34 thousand dollars, whether acquired by purchase, lease, or 35 -14- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 14/ 21

donation. 1 h. e. (1) Any acquisition by or on behalf of a health 2 care provider or group of health care providers of any piece of 3 equipment with a value in excess of one million five hundred 4 thousand dollars , whether acquired by purchase, lease, or 5 donation, which results in the offering or development of a 6 health service not previously provided that has a value in 7 excess of the following amount: 8 (a) Beginning on or after January 1, 2027, and before 9 December 31, 2031, four million dollars . 10 (b) Beginning on or after January 1, 2032, and before 11 December 31, 2036, four million five hundred thousand dollars. 12 (c) Beginning on or after January 1, 2037, five million 13 dollars. 14 (2) A mobile health service provided on a contract basis 15 is not considered to have been previously provided by a health 16 care provider or group of health care providers. 17 i. Any acquisition by or on behalf of an institutional 18 health facility or a health maintenance organization of any 19 piece of replacement equipment with a value in excess of one 20 million five hundred thousand dollars, whether acquired by 21 purchase, lease, or donation. 22 j. f. (1) Any acquisition by or on behalf of an 23 institutional health facility or health maintenance 24 organization of any piece of equipment with a value in excess 25 of one million five hundred thousand dollars , whether acquired 26 by purchase, lease, or donation, which results in the offering 27 or development of a health service not previously provided that 28 has a value in excess of the following amount: 29 (a) Beginning on or after January 1, 2027, and before 30 December 31, 2031, four million dollars . 31 (b) Beginning on or after January 1, 2032, and before 32 December 31, 2036, four million five hundred thousand dollars. 33 (c) Beginning on or after January 1, 2037, five million 34 dollars. 35 -15- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 15/ 21

(2) A mobile health service provided on a contract basis 1 is not considered to have been previously provided by an 2 institutional health facility. 3 k. Any air transportation service for transportation of 4 patients or medical personnel offered through an institutional 5 health facility at a specific time but which was not offered 6 on a regular basis in or through that institutional health 7 facility within the twelve-month period prior to the specific 8 time. 9 l. g. Any A mobile health service with a value in excess of 10 one four million five hundred thousand dollars. 11 m. Any of the following: 12 (1) Cardiac catheterization service. 13 (2) Open heart surgical service. 14 (3) Organ transplantation service. 15 (4) Radiation therapy service applying ionizing radiation 16 for the treatment of malignant disease using megavoltage 17 external beam equipment. 18 Sec. 12. Section 135.62, subsection 1, Code 2026, is amended 19 to read as follows: 20 1. a. A new institutional health service or changed 21 institutional health service shall not be offered or developed 22 in this state without prior application to the department 23 for , and receipt of , a certificate of need, pursuant to this 24 subchapter . 25 b. The application shall be made upon on forms furnished or 26 prescribed by the department and shall contain such information 27 as required by the department may require under this subchapter 28 by rule adopted pursuant to chapter 17A . 29 c. (1) The application shall be accompanied by a fee 30 equivalent to three-tenths of one percent of the anticipated 31 cost of the project with a minimum fee of six hundred dollars 32 and a maximum fee of twenty-one thousand dollars. The fee 33 shall be remitted by the department to the treasurer of state , 34 who shall place it for deposit in the general fund of the 35 -16- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 16/ 21

state. An applicant for a new institutional health service or 1 a changed institutional health service offered or developed by 2 an intermediate care facility for persons with an intellectual 3 disability or an intermediate care facility for persons with 4 mental illness, as each of those terms are defined in section 5 135C.1, shall not be required to pay the application fee. 6 (2) If an application is voluntarily withdrawn within 7 thirty calendar days after submission, seventy-five percent 8 of the application fee shall be refunded ; if the application 9 is voluntarily withdrawn more than thirty but within sixty 10 days after submission, fifty percent of the application fee 11 shall be refunded; if the application is withdrawn voluntarily 12 more than sixty days after submission, twenty-five percent of 13 the application fee shall be refunded . Notwithstanding the 14 required payment of an application fee under this subsection , 15 an applicant for a new institutional health service or a 16 changed institutional health service offered or developed by 17 an intermediate care facility for persons with an intellectual 18 disability or an intermediate care facility for persons with 19 mental illness as defined pursuant to section 135C.1 is exempt 20 from payment of the application fee. 21 Sec. 13. Section 135.62, subsection 2, paragraphs a and e, 22 Code 2026, are amended to read as follows: 23 a. Private offices and private clinics of an individual 24 physician, dentist, or other practitioner or group of 25 health care providers, except as provided by section 135.61, 26 subsection 16 , paragraphs “g” , “h” , and “m” paragraph “e” , and 27 section 135.61, subsections 2 and 18 . 28 e. A health maintenance organization or combination of 29 health maintenance organizations or an institutional health 30 facility controlled directly or indirectly by a health 31 maintenance organization or combination of health maintenance 32 organizations, except when the health maintenance organization 33 or combination of health maintenance organizations does any of 34 the following: 35 -17- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 17/ 21

(1) Constructs, develops, renovates, relocates, or 1 otherwise establishes an institutional health facility. 2 (2) Acquires major medical equipment as provided by section 3 135.61, subsection 16, paragraphs “i” and “j” paragraph “f” . 4 Sec. 14. Section 135.62, subsection 2, paragraph h, 5 subparagraph (2), Code 2026, is amended to read as follows: 6 (2) If these conditions are not met, the institutional 7 health facility or health maintenance organization is subject 8 to review as a “new institutional health service” or “changed 9 institutional health service” under section 135.61, subsection 10 16 , paragraph “f” , and is subject to sanctions under section 11 135.72 . 12 Sec. 15. Section 135.62, subsection 2, Code 2026, is amended 13 by adding the following new paragraphs: 14 NEW PARAGRAPH . r. An organized outpatient health 15 facility that provides behavioral health services as defined 16 by the department by rule, including but not limited to 17 substitution-based treatment centers for opiate addiction. 18 NEW PARAGRAPH . s. Open heart surgical services. 19 NEW PARAGRAPH . t. Organ transplantation services. 20 NEW PARAGRAPH . u. Radiation therapy services. 21 NEW PARAGRAPH . v. Cardiac catheterization services. 22 Sec. 16. Section 135.63, subsection 2, paragraph b, Code 23 2026, is amended by striking the paragraph. 24 Sec. 17. Section 135.65, subsections 1 and 2, Code 2026, are 25 amended to read as follows: 26 1. a. Within fifteen business days after receipt of the 27 date the department receives an application for a certificate 28 of need, the department shall examine the application for form 29 and completeness and accept or reject it. An application 30 shall be rejected only if it fails to provide all information 31 required by the department pursuant to section 135.62, 32 subsection 1 . The department shall promptly return to the 33 applicant any a rejected application , to the applicant with an 34 explanation of the reasons for its rejection. 35 -18- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 18/ 21

b. Within thirty calendar days of the date the department 1 sends a rejected application to an applicant, the applicant may 2 revise and resubmit the application once for review without 3 submitting another application fee under section 135.62. 4 2. Upon acceptance of an application for a certificate 5 of need, the department shall promptly undertake to notify 6 all affected persons in writing through electronic means 7 that formal review of the application has been initiated. 8 Notification to those affected persons who are consumers 9 or third-party payers or other payers for health services 10 may be provided by electronic distribution of the pertinent 11 information to the news media . 12 Sec. 18. Section 135.65, subsection 3, paragraph b, Code 13 2026, is amended to read as follows: 14 b. A period for the submission of written public hearing 15 comments from affected persons on the application, to be held 16 scheduled prior to completion of the evaluation required by 17 paragraph “a” . 18 Sec. 19. Section 135.65, subsection 4, Code 2026, is amended 19 by striking the subsection. 20 Sec. 20. Section 135.66, subsection 1, Code 2026, is amended 21 to read as follows: 22 1. The department may waive the letter of intent procedures 23 prescribed by section 135.64 and substitute conduct a summary 24 review procedure, which shall be established by rules of 25 adopted by the department, when it the department accepts an 26 application for a certificate of need for a project which that 27 meets any of the following criteria in paragraphs “a” through 28 “e” : 29 a. A project which is limited to repair or replacement of a 30 facility or equipment damaged or destroyed by a disaster, and 31 which will not expand the facility nor increase the services 32 provided beyond the level existing prior to the disaster. 33 b. A project necessary to enable the facility or service to 34 achieve or maintain compliance with federal, state, or other 35 -19- SF 2421.3168 (1) 91 (amending this SF 2421 to CONFORM to HF 2635) nls/ko 19/ 21