249NIOWA HEALTH AND WELLNESS PLAN249N.1Title.This chapter shall be known and may be cited as the “Iowa Health and Wellness Plan”.2013 Acts, ch 138, §166, 187249N.2Definitions.As used in this chapter, unless the context otherwise requires:1“Accountable care organization” means a risk-bearing, integrated health care organization characterized by a payment and care delivery model that ties provider reimbursement to quality metrics and reductions in the total cost of care for an attributed population of patients.2“Affordable Care Act” means the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152.3“Covered benefits” means covered benefits as specified in section 249N.5.4“Department” means the department of health and human services.5“Director” means the director of health and human services.6“Eligible individual” means an individual eligible for medical assistance pursuant to section 249A.3, subsection 1, paragraph “v”.7“Essential health benefits” means essential health benefits as defined in section 1302 of the Affordable Care Act, that include at least the general categories and the items and services covered within the categories of ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. 8“Federal approval” means approval by the centers for Medicare and Medicaid services of the United States department of health and human services.9“Federal poverty level” means the most recently revised poverty income guidelines published by the United States department of health and human services.10“Household income” means household income as determined using the modified adjusted gross income methodology pursuant to section 2002 of the Affordable Care Act.11“Iowa health and wellness plan” or “plan” means the Iowa health and wellness plan established under this chapter.12“Iowa health and wellness plan provider” means any provider enrolled in the medical assistance program or any participating accountable care organization.13“Iowa health and wellness plan provider network” means the health care delivery network approved by the department for Iowa health and wellness plan members.14“Medical assistance program”, “Medicaid program”, or “Medicaid” means the program paying all or part of the costs of care and services provided to an individual pursuant to chapter 249A and Tit. XIX of the federal Social Security Act.15“Medical home” means a team approach to providing health care that originates in a primary care setting; fosters a partnership among the patient, the personal provider, and other health care professionals, and where appropriate, the patient’s family; utilizes the partnership to access and integrate all medical and nonmedical health-related services across all elements of the health care system and the patient’s community as needed by the patient and the patient’s family to achieve maximum health potential; maintains a centralized, comprehensive record of all health-related services to promote continuity of care; and has all of the following characteristics:aA personal provider.bA provider-directed team-based medical practice.cWhole-person orientation.dCoordination and integration of care.eQuality and safety.fEnhanced access to health care.gA payment system that appropriately recognizes the added value provided to patients who have a patient-centered medical home.16“Member” means an eligible individual who is enrolled in the Iowa health and wellness plan.17“Participating accountable care organization” means an accountable care organization approved by the department to participate in the Iowa health and wellness plan provider network.18“Personal provider” means the patient’s first point of contact in the health care system with a primary care provider who identifies the patient’s health-related needs and, working with a team of health care professionals and providers of medical and nonmedical health-related services, provides for and coordinates appropriate care to address the health-related needs identified.19“Preventive care services” means care that is provided to an individual to promote health, prevent disease, or diagnose disease.20“Primary care provider” includes but is not limited to any of the following licensed or certified health care professionals who provide primary care:aA physician who is a family or general practitioner, a pediatrician, an internist, an obstetrician, or a gynecologist. bAn advanced registered nurse practitioner.cA physician assistant.dA chiropractor.21“Primary medical provider” means the personal provider trained to provide first contact and continuous and comprehensive care to a member, chosen by a member or to whom a member is assigned under the Iowa health and wellness plan.22“Value-based reimbursement” means a payment methodology that links provider reimbursement to improved performance by health care providers by holding health care providers accountable for both the cost and quality of care provided.2013 Acts, ch 138, §167, 187; 2017 Acts, ch 148, §6, 7; 2023 Acts, ch 19, §826249N.3Purpose establishment of Iowa health and wellness plan limitation.1The purpose of this chapter is to establish and provide for the administration of an Iowa health and wellness plan to promote all of the following:aIncreased access to health care through a patient-centered, integrated health care system.bImproved quality health care outcomes.cIncentives to encourage personal responsibility, cost-conscious utilization of health care, and adoption of preventive practices and healthy behaviors.dHealth care cost containment and minimization of administrative costs.2The Iowa health and wellness plan is established within the medical assistance program and shall be administered by the department. Except as otherwise specified in this chapter, provisions applicable to the medical assistance program pursuant to chapter 249A shall be applicable to the Iowa health and wellness plan.3The department may contract with a third-party administrator to provide eligibility determination support, and to administer enrollment, member outreach, and other components of the Iowa health and wellness plan.4The provisions of this chapter shall not be construed and are not intended to affect the provision of services to medical assistance program recipients existing on January 1, 2014.5aIf the methodology for calculating the federal medical assistance percentage for eligible individuals, as provided in 42 U.S.C. §1396d(y), is modified through federal law or regulation, in a manner that reduces the percentage of federal assistance to the state in a manner inconsistent with 42 U.S.C. §1396d(y), or if federal law or regulation affecting eligibility or benefits for the Iowa health and wellness plan is modified, the department may implement an alternative plan as specified in the medical assistance state plan or waiver for coverage of the affected population, subject to prior, statutory approval of implementation of the alternative plan.bIf the methodology for calculating the federal medical assistance percentage for eligible individuals, as provided in 42 U.S.C. §1396d(y), is modified through federal law or regulation resulting in a reduction of the percentage of federal assistance to the state below ninety percent but not below eighty-five percent, the medical assistance program reimbursement rates for inpatient and outpatient hospital services shall be reduced by a like percentage in the succeeding fiscal year, subject to prior, statutory approval of implementation of the reduction.2013 Acts, ch 138, §168, 187249N.4Iowa health and wellness plan eligibility.1Except as otherwise provided in this chapter, an individual may participate in the Iowa health and wellness plan if the individual meets all of the following criteria:aIs an eligible individual.bMeets the citizenship or alienage requirements of the medical assistance program, is a resident of Iowa, and provides a social security number upon application for the plan.cFulfills all other conditions of participation in the Iowa health and wellness plan, including member financial participation pursuant to section 249N.7.2An individual who has access to affordable employer-sponsored health care coverage, as defined by rule of the department to align with regulations adopted by the federal internal revenue service under the Affordable Care Act, shall not be eligible for participation in the Iowa health and wellness plan.3Each applicant for the Iowa health and wellness plan shall provide to the department all insurance information required by the health insurance premium payment program in accordance with rules adopted by the department.aThe department may elect to pay the cost of premiums for applicants with access to employer-sponsored health care coverage if the department determines such payment to be cost-effective.bEligibility for the Iowa health and wellness plan is a qualifying event under the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.cIf premium payment is provided under this subsection for employer-sponsored health care coverage, the Iowa health and wellness plan shall supplement such coverage as necessary to provide the covered benefits specified under section 249N.5.4The department shall implement the Iowa health and wellness plan in a manner that ensures that the Iowa health and wellness plan is the payor of last resort.5A member is eligible for coverage effective the first day of the month following the month of application for enrollment.6Following initial enrollment, a member is eligible for covered benefits for twelve months, subject to program termination and other limitations otherwise specified in this chapter. The department shall review the member’s eligibility on at least an annual basis.2013 Acts, ch 138, §169, 187249N.4AWork requirements.1The department shall request any federal approval necessary to include work requirements as a condition of a member maintaining eligibility for the Iowa health and wellness plan.2The goal of including work requirements is to reduce the dependence of low-income Iowans on public assistance programs through efforts that advance economic stability and mobility.3The department shall require as a condition of maintaining eligibility for the Iowa health and wellness plan that a member work at least eighty hours each month, as determined by the department.4The department shall exempt an individual from the work requirements for the Iowa health and wellness plan if the individual meets any of the following criteria:aThe individual is under nineteen years of age.bThe individual is sixty-five years of age or older.cThe individual is determined to be disabled by the United States social security administration.dThe individual is identified as medically frail or medically exempt under the Medicaid program.eThe individual is a caretaker of a dependent child under six years of age.fThe individual is pregnant and the pregnancy is high risk.gThe individual is receiving unemployment compensation as determined by the department of workforce development.hThe individual is participating in substance use disorder treatment, not to exceed a consecutive six-month period.iThe individual is otherwise exempt for good cause as determined by the director.5To maximize fiscal stability and administrative efficiency, any exemption applied under the Iowa health and wellness plan shall be substantially similar to the exemptions applied under other public assistance programs.6Upon the department’s receipt of federal approval, and the department’s operationalizing of a real-time system to facilitate recipient reporting and department evaluation efforts, the department shall implement work requirements as a condition of maintaining eligibility for the Iowa health and wellness plan. The department shall adopt rules pursuant to chapter 17A as necessary to administer the work requirements for the Iowa health and wellness plan.7The department may resubmit a request for federal approval submitted under subsection 1 if the initial request is denied or withdrawn for any reason.8If the department receives federal approval to include work requirements as a condition of a member maintaining eligibility for the Iowa health and wellness plan, and if federal law or regulations affecting work requirements for the Iowa health and wellness plan are modified to exclude work requirements as a condition of a member maintaining eligibility as provided in this section, the department shall discontinue the Iowa health and wellness plan, subject to federal approval. If, under federal law, the department is not allowed to discontinue the Iowa health and wellness plan, the department may implement an alternative plan as specified in the medical assistance state plan or waiver for coverage of the affected population, subject to prior statutory approval of implementation of the alternative plan.2025 Acts, ch 133, §1, 2249N.5Iowa health and wellness plan covered benefits administration.1Iowa health and wellness plan members shall receive coverage for benefits as specified in section 249A.3, subsection 1, paragraph “v”.2aFor members whose household income is at or below one hundred percent of the federal poverty level, the plan shall be administered by the Medicaid program consistent with program administration applicable to individuals under section 249A.3, subsection 1.bFor members whose household income is above one hundred percent but not in excess of one hundred thirty-three percent of the federal poverty level, the plan shall be administered through provision of premium assistance for the purchase of the covered benefits through the American health benefits exchange created pursuant to the Affordable Care Act. The department may pay premiums and supplemental cost-sharing subsidies directly to qualified health plans participating in the American health benefits exchange created pursuant to the Affordable Care Act on behalf of the member.2013 Acts, ch 138, §170, 187; 2023 Acts, ch 19, §827249N.6Iowa health and wellness plan provider network.1The Iowa health and wellness plan provider network shall include all providers enrolled in the medical assistance program and all participating accountable care organizations. Reimbursement under this chapter shall only be made to such Iowa health and wellness plan providers for covered benefits.2aUpon enrollment, a member shall choose a primary medical provider and, to the extent feasible, shall also choose a medical home within the Iowa health and wellness plan provider network.bIf the member does not choose a primary medical provider or a medical home, the department shall assign the member to a primary medical provider or a medical home in accordance with the Medicaid managed health care, mandatory enrollment provisions specified in rules adopted by the department pursuant to chapter 249A and in accordance with quality data available to the department.cThe department shall develop a mechanism for primary medical providers, medical homes, and participating accountable care organizations to jointly facilitate member care coordination. The Iowa health and wellness plan shall provide for reimbursement of care coordination services provided under the plan.3aThe department shall provide procedures for accountable care organizations that emerge through local markets to participate in the Iowa health and wellness plan provider network. Such accountable care organizations shall incorporate the medical home as a foundation and shall emphasize whole-person orientation and coordination and integration of both clinical services and nonclinical community and social supports that address social determinants of health. A participating accountable care organization shall enter into a contract with the department to ensure the coordination and management of the health of attributed members, to produce quality health care outcomes, and to control overall cost.bThe department shall establish by rule in accordance with chapter 17A the qualifications, contracting processes, and contract terms for a participating accountable care organization. The rules shall also establish a methodology for attribution of a member to a participating accountable care organization.cA participating accountable care organization contract shall establish accountability based on quality performance and total cost-of-care metrics for the attributed population. In developing quality performance standards, the department shall consider those utilized by state accountable care organization models including but not limited to the quality index score and the Medicare shared savings program quality reporting metrics. The payment models shall include but are not limited to risk sharing, including both shared savings and shared costs, between the state and the participating accountable care organization, and bonus payments for improved quality. The contract terms shall require that a participating accountable care organization is subject to shared savings beginning with the initial year of the contract, must have quality metrics in place within three years of the initial year of the contract, and must participate in risk sharing within five years of the initial year of the contract.4To the greatest extent possible, members shall have a choice of providers within the Iowa health and wellness plan provider network to facilitate access to locally-based health care providers and services. However, member choice may be limited by the results of attribution under this section and by the participating accountable care organization, with prior approval of the department, if the member’s health condition would benefit from limiting the member’s choice of an Iowa health and wellness plan provider to ensure coordination of services, or due to overutilization of covered benefits. The participating accountable care organization shall provide thirty days’ notice to the member prior to limitation of such choice.5aAn Iowa health and wellness plan provider shall be reimbursed for covered benefits under the Iowa health and wellness plan utilizing the same reimbursement methodology as that applicable to individuals eligible for medical assistance under section 249A.3, subsection 1.bNotwithstanding paragraph “a”, a participating accountable care organization under contract with the department shall be reimbursed utilizing a value-based reimbursement methodology.6aIowa health and wellness plan providers shall exchange member health information as provided by rule to facilitate coordination and management of members’ health, quality health care outcomes, and containment of and reduction in costs.bThe department shall provide the health care claims data of attributed members to a member’s participating accountable care organization on a timeframe established by rule of the department.2013 Acts, ch 138, §171, 187; 2017 Acts, ch 148, §8, 9249N.7Member financial participation.1Membership in the Iowa health and wellness plan shall require payment of monthly contributions for members whose household income is at or above fifty percent of the federal poverty level. Members shall be subject to copayment amounts applicable only to nonemergency use of a hospital emergency department. Total member cost-sharing, annually, shall align with the cost-sharing limitations requirements for the American health benefits exchanges under the Affordable Care Act. Contributions and copayment amounts shall be established by rule of the department.2Contributions shall be waived for a member during the initial year of membership. If a member completes all required preventive care services and wellness activities as specified by rule of the department during the initial year of membership, contributions shall be waived during the subsequent year of membership and each year thereafter until such time as the member fails to complete required preventive care services and wellness activities specified during the prior annual membership period.2013 Acts, ch 138, §172, 187249N.8Behavioral health services reports.The department shall annually submit a report to the governor and the general assembly with details related to the department’s review of the funds administered by, and the outcomes and effectiveness of, the behavioral health services provided by, the behavioral health service system established in section 225A.3.2013 Acts, ch 138, §173, 187; 2021 Acts, ch 177, §84, 108; 2024 Acts, ch 1161, §104, 137