House File 2445
HOUSE FILE
BY OSTERHAUS, FALLON, BUKTA,
WINCKLER, STEVENS, MASCHER,
GASKILL, LENSING, GREIMANN,
SHOULTZ, MILLER, JOCHUM,
T. TAYLOR, D. OLSON, SMITH,
WHITEAD, WHITAKER, HUNTER,
WENDT, THOMAS, JACOBY, FORD,
SWAIM, SHOMSHOR, D. TAYLOR,
MURPHY, HEDDENS, REASONER,
QUIRK, MERTZ, CONNORS, KUHN,
and COHOON
Passed House, Date Passed Senate, Date
Vote: Ayes Nays Vote: Ayes Nays
Approved
A BILL FOR
1 An Act relating to the establishment of a healthy Iowa for all
2 program.
3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
4 TLSB 6312HH 80
5 pf/gg/14
PAG LIN
1 1 Section 1. NEW SECTION. 514M.1 SHORT TITLE.
1 2 This chapter shall be known and may be cited as the
1 3 "Healthy Iowa for All" program.
1 4 Sec. 2. NEW SECTION. 514M.2 LEGISLATIVE INTENT.
1 5 It is the intent of the general assembly to establish the
1 6 healthy Iowa for all program to provide access to
1 7 comprehensive, quality, affordable health care coverage to
1 8 eligible small employers, including the self=employed, their
1 9 employees and their dependents, state employees and their
1 10 dependents, local government employees and their dependents,
1 11 and individuals, on a voluntary basis. It is also the intent
1 12 of the general assembly that the healthy Iowa for all program
1 13 monitor and improve the quality of health care in the state.
1 14 Sec. 3. NEW SECTION. 514M.3 DEFINITIONS.
1 15 As used in this chapter, unless the context otherwise
1 16 requires:
1 17 1. "Board" means the HIFA program board created in section
1 18 514M.6.
1 19 2. "Department" means the Iowa department of public
1 20 health.
1 21 3. "Dependent" means a spouse, an unmarried child under
1 22 nineteen years of age, a child who is a student under twenty=
1 23 three years of age and is financially dependent upon a plan
1 24 enrollee, or a person of any age who is the child of a plan
1 25 enrollee and is disabled and dependent upon that plan
1 26 enrollee. "Dependent" may include a domestic partner.
1 27 4. "Director" means the director of public health.
1 28 5. "Eligible employer" means a business that employs at
1 29 least two but not more than fifty eligible employees, the
1 30 majority of whom are employed in the state, including a
1 31 municipality or political subdivision that has fifty or fewer
1 32 employees.
1 33 6. "Eligible individual" means any of the following:
1 34 a. A self=employed individual who works and resides in the
1 35 state, and is organized as a sole proprietorship or in any
2 1 other legally recognized manner in which a self=employed
2 2 individual may organize, a substantial part of whose income
2 3 derives from a trade or business through which the individual
2 4 has attempted to earn taxable income.
2 5 b. An unemployed individual who resides in this state.
2 6 c. An individual employed by an employer that does not
2 7 offer health insurance.
2 8 d. Uninsured individuals without access to employer
2 9 coverage.
2 10 7. "Eligible local government employee" means a local
2 11 government employee.
2 12 8. "Eligible state employee" means a state employee,
2 13 including a state employee covered under a collective
2 14 bargaining agreement.
2 15 9. "Employer" means the owner or responsible agent of a
2 16 business authorized to sign contracts on behalf of the
2 17 business.
2 18 10. "Federal poverty guidelines" means the federal poverty
2 19 guidelines issued by the United States department of health
2 20 and human services in the federal register.
2 21 11. "Health insurance carrier" means any entity licensed
2 22 by the division of insurance of the department of commerce to
2 23 provide health insurance in Iowa or an organized delivery
2 24 system licensed by the director of public health that has
2 25 contracted with the department to provide health insurance
2 26 coverage to eligible individuals and dependents under this
2 27 chapter.
2 28 12. "HIFA health insurance" means the health insurance
2 29 product established by the HIFA program that is offered by a
2 30 private health insurance carrier.
2 31 13. "HIFA health insurance program" or "insurance program"
2 32 means the program through which HIFA health insurance is
2 33 provided.
2 34 14. "HIFA program" or "program" means the healthy Iowa for
2 35 all program established in this chapter.
3 1 15. "Local government" means a city, county, school
3 2 district, and the institutions governed by the board of
3 3 regents.
3 4 16. "Modified community rating" means a method used to
3 5 develop a health insurance carrier's premiums which spreads
3 6 financial risk across a population by limiting the utilization
3 7 of health status and claims experience as approved by the
3 8 commissioner of insurance.
3 9 17. "Participating employer" means an eligible employer
3 10 that contracts with and has employees enrolled in the HIFA
3 11 health insurance program.
3 12 18. "Plan enrollee" means an eligible individual or
3 13 eligible employee who enrolls in the HIFA health insurance
3 14 program.
3 15 19. "Provider" means any person, organization,
3 16 corporation, or association that provides health care services
3 17 and products and is authorized to provide those services and
3 18 products under state law.
3 19 20. "Reinsurance" means an agreement between insurance
3 20 companies under which one accepts all or part of the risk or
3 21 loss of the other.
3 22 21. "Third=party administrator" means any person who, on
3 23 behalf of any person who establishes a health insurance plan
3 24 covering residents of this state, receives or collects
3 25 charges, contributions, or premiums for, or settles claims of
3 26 residents in connection with, any type of health benefit
3 27 provided in or as an alternative to insurance.
3 28 22. "Unemployed individual" means an individual who does
3 29 not work more than twenty hours per week for any single
3 30 employer.
3 31 Sec. 4. NEW SECTION. 514M.4 HIFA PROGRAM ESTABLISHED.
3 32 1. The department shall establish the HIFA program to
3 33 provide access to health care coverage to eligible employers,
3 34 including the self=employed, their employees and dependents,
3 35 eligible state employees and their dependents, eligible local
4 1 government employees and their dependents, and eligible
4 2 individuals.
4 3 2. The department may do any of the following:
4 4 a. Have and exercise all powers necessary or convenient to
4 5 effect the purposes for which the program is organized or to
4 6 further the activities in which the program may lawfully be
4 7 engaged, including the establishment of the insurance program.
4 8 b. Make and alter a plan of operation, not inconsistent
4 9 with this chapter or with state law, for the administration
4 10 and regulation of the activities of the program.
4 11 c. Take any legal actions necessary or proper to recover
4 12 or collect savings offset payments due the program or that are
4 13 necessary for the proper administration of the program.
4 14 d. Take any legal actions necessary to avoid the payment
4 15 of improper claims against the insurance program or the
4 16 coverage provided by or through the insurance program to
4 17 recover any amounts erroneously or improperly paid by the
4 18 insurance program, to recover amounts paid by the insurance
4 19 program as the result of mistake of fact or law, and to
4 20 recover other amounts due the insurance program.
4 21 e. Enter into contracts with qualified third parties, both
4 22 private and public, for any service necessary to carry out the
4 23 purposes of this chapter.
4 24 f. Conduct studies and analyses related to the provision
4 25 of health care, health care costs, and health care quality.
4 26 g. Accept appropriations, gifts, grants, loans, or other
4 27 aid from public or private entities.
4 28 h. Contract with organizations with expertise in health
4 29 care data, including a nonprofit health data processing entity
4 30 in this state, to assist the Iowa quality forum established in
4 31 section 514M.13 in the performance of its responsibilities.
4 32 i. Provide staff support and other assistance to the Iowa
4 33 quality forum established in section 514M.13.
4 34 j. In accordance with the limitations and restrictions of
4 35 this chapter, cause any of its powers or duties to be carried
5 1 out by one or more organizations organized, created, or
5 2 operated under the laws of this state.
5 3 3. The department shall do all of the following:
5 4 a. Establish administrative and accounting procedures as
5 5 recommended by the state auditor for the operation of the
5 6 program.
5 7 b. Collect the savings offset payments as provided in
5 8 section 514M.11.
5 9 c. Determine the comprehensive services and benefits to be
5 10 included in HIFA health insurance and make recommendations to
5 11 the board regarding the services and benefits.
5 12 d. Develop and implement an outreach program to publicize
5 13 the existence of the HIFA program and the HIFA health
5 14 insurance program and the eligibility requirements and the
5 15 enrollment procedures for the HIFA health insurance program
5 16 and to maintain public awareness of the HIFA program and the
5 17 HIFA health insurance program.
5 18 e. Arrange for the provision of HIFA health insurance
5 19 benefit coverage to eligible individuals, eligible employees,
5 20 eligible state employees, and eligible local government
5 21 employees through contracts with one or more qualified health
5 22 insurance carriers.
5 23 f. Develop a high=risk pool for plan enrollees in HIFA
5 24 health insurance in accordance with the provisions of section
5 25 514M.15.
5 26 4. Financial and performance audits or examinations of
5 27 HIFA health insurance shall be conducted by the insurance
5 28 division of the department of commerce, annually. A copy of
5 29 any audit shall be provided to the commissioner of insurance,
5 30 the governor, and the general assembly.
5 31 5. Beginning September 1, 2006, and annually thereafter,
5 32 the department shall submit a report to the governor and the
5 33 general assembly on the impact of the HIFA health insurance
5 34 program on the small group, individual, state employee, and
5 35 local government employee health insurance markets in this
6 1 state and any reduction in the number of uninsured individuals
6 2 in the state. The department shall also report on membership
6 3 in the HIFA health insurance program, the administrative
6 4 expenses of the HIFA health insurance program, the extent of
6 5 coverage, the effect on premiums, the number of covered lives,
6 6 the number of HIFA health insurance policies issued or
6 7 renewed, and HIFA health insurance premiums earned and claims
6 8 incurred by health insurance carriers offering HIFA health
6 9 insurance.
6 10 6. The department shall coordinate the activities of the
6 11 HIFA program with health care programs offered through
6 12 federal, state, and local governments.
6 13 Sec. 5. NEW SECTION. 514M.5 HIFA PROGRAM BOARD.
6 14 1. A HIFA program board for the HIFA program is
6 15 established. The board shall meet not less than four times
6 16 annually or at the call of the chairperson for the purposes of
6 17 establishing policy and adopting rules for the program. The
6 18 board shall consist of the following members:
6 19 a. Five public voting members who have knowledge or
6 20 experience in one or more of the following areas, appointed by
6 21 the governor and subject to confirmation by the senate:
6 22 (1) Health care purchasing.
6 23 (2) Health insurance.
6 24 (3) Health policy and law.
6 25 (4) State management and budgeting.
6 26 (5) Health care financing.
6 27 b. The director of public health, the director of human
6 28 services, and the commissioner of insurance serving as ex
6 29 officio, nonvoting members of the board.
6 30 c. Two members of the senate and two members of the house
6 31 of representatives, serving as ex officio, nonvoting members.
6 32 The legislative members of the board shall be appointed by the
6 33 majority leader of the senate, after consultation with the
6 34 president of the senate, and by the minority leader of the
6 35 senate, and by the speaker of the house, after consultation
7 1 with the majority leader, and by the minority leader of the
7 2 house of representatives. Legislative members shall receive
7 3 compensation pursuant to section 2.12.
7 4 2. Members appointed by the governor shall serve two=year
7 5 staggered terms as designated by the governor, and legislative
7 6 members of the board shall serve two=year terms. The filling
7 7 of vacancies, membership terms, payment of compensation and
7 8 expenses, and removal of the members who are representatives
7 9 of the public are governed by chapter 69. Members of the
7 10 board are entitled to receive reimbursement of actual expenses
7 11 incurred in the discharge of their duties. Public members of
7 12 the board are also eligible to receive per diem as specified
7 13 in section 7E.6 for each day spent in performance of duties as
7 14 members. The members shall select a voting member as the
7 15 chairperson on an annual basis from among the membership of
7 16 the board. Three voting members of the board constitute a
7 17 quorum. An action taken by the board shall require the
7 18 affirmative vote of at least three members.
7 19 3. A member of the board or an employee of the HIFA
7 20 program or their dependent shall not receive any direct
7 21 personal benefit from the activities of the program in
7 22 assisting any private entity, except that they may participate
7 23 in HIFA health insurance on the same terms as any other
7 24 participant.
7 25 4. The board shall do all of the following:
7 26 a. Employ or contract for any personnel as may be
7 27 necessary to carry out the duties of the board.
7 28 b. Develop standards for selecting participating health
7 29 insurance carriers for the insurance program.
7 30 c. Establish penalties for breach of contract or other
7 31 violations of requirements or provisions under the program.
7 32 d. In consultation with the Iowa quality forum advisory
7 33 council, select a nationally recognized functional health
7 34 assessment form for an initial assessment of all eligible
7 35 employees, eligible individuals, eligible state employees, and
8 1 eligible local government employees participating in the HIFA
8 2 health insurance program, establish a baseline for comparison
8 3 purposes, and develop appropriate indicators to measure the
8 4 health status of those participating in the program.
8 5 e. Specify the data to be maintained by the department,
8 6 including data to be collected for the purposes of quality
8 7 assurance reports.
8 8 f. Approve the benefits package design, review the
8 9 benefits package design on a periodic basis, and make
8 10 necessary changes in the benefit design to reflect the results
8 11 of the periodic reviews. The benefits package shall provide
8 12 comprehensive coverage and shall include all benefits mandated
8 13 by law.
8 14 g. Determine the contribution levels, deductibles, and
8 15 cost=sharing requirements of the HIFA health insurance
8 16 program.
8 17 h. Provide for periodic assessment of the effectiveness of
8 18 the outreach program.
8 19 i. Solicit input from the public regarding the program and
8 20 related issues and services.
8 21 j. Approve a high=risk pool for plan enrollees in the HIFA
8 22 health insurance program.
8 23 k. Adopt rules, in accordance with chapter 17A, as
8 24 necessary for the proper administration and enforcement of
8 25 this chapter.
8 26 5. State agencies shall provide technical assistance and
8 27 expertise to the board and the department upon request. The
8 28 attorney general shall act as legal counsel to the board.
8 29 6. The board may appoint advisory committees to assist the
8 30 board and the department.
8 31 Sec. 6. NEW SECTION. 514M.6 HIFA HEALTH INSURANCE
8 32 PROGRAM.
8 33 1. a. The HIFA health insurance program shall provide for
8 34 health benefits coverage through health insurance carriers
8 35 that apply to the board and meet the qualifications described
9 1 in this section and any additional qualifications established
9 2 by rule of the board.
9 3 b. If a sufficient number of health insurance carriers do
9 4 not apply to offer and deliver health insurance under the
9 5 insurance program, the board may propose the establishment of
9 6 a nonprofit health care plan or may propose the expansion of
9 7 an existing public plan. If the board proposes the
9 8 establishment of a nonprofit health care plan or the expansion
9 9 of an existing public plan, the board shall submit a proposal,
9 10 including but not limited to a funding mechanism, to
9 11 capitalize a nonprofit health care plan and any recommended
9 12 legislation to the general assembly. The program shall not
9 13 provide access to health insurance by establishing a nonprofit
9 14 health care plan or through an existing public plan without
9 15 specific legislative approval.
9 16 2. Nothing in this chapter shall be construed or is
9 17 intended as, or shall imply, a grant of entitlement for
9 18 services to persons who are eligible for participation in the
9 19 HIFA health insurance program based upon eligibility
9 20 consistent with the requirements of this chapter. Any state
9 21 obligation to provide services pursuant to this chapter is
9 22 limited to the extent of the funds appropriated or provided
9 23 for implementation of this chapter.
9 24 3. The HIFA health insurance program may contract with
9 25 health insurance carriers licensed to sell health insurance in
9 26 the state or other private or public third=party
9 27 administrators to provide insurance under the insurance
9 28 program.
9 29 a. The HIFA health insurance program shall issue requests
9 30 for proposals to select health insurance carriers.
9 31 b. The insurance program may include quality improvement,
9 32 patient care management, and cost=containment provisions in
9 33 the contracts with participating health insurance carriers or
9 34 may arrange for the provision of such services through
9 35 contracts with other entities.
10 1 c. The insurance program shall require participating
10 2 health insurance carriers to offer a benefit plan identical to
10 3 the plan developed by the board in the small group market.
10 4 d. The HIFA health insurance program may set allowable
10 5 rates for administration and underwriting gains for the
10 6 insurance program.
10 7 e. The HIFA health insurance program may administer
10 8 continuation benefits for eligible individuals from employers
10 9 with twenty or more employees who have purchased health
10 10 insurance coverage through the program for the duration of
10 11 their eligibility periods for continuation of benefits
10 12 pursuant to Title X of the federal Consolidated Omnibus Budget
10 13 Reconciliation Act of 1986, Pub. L. No. 99=272, sections 10001
10 14 to 10003.
10 15 f. The HIFA health insurance program may administer or
10 16 contract to administer the United States Internal Revenue Code
10 17 of 1986, section 125, plans for employers and employees
10 18 participating in the program, including medical expense
10 19 reimbursement accounts and dependent care reimbursement
10 20 accounts.
10 21 g. The HIFA health insurance program shall contract with
10 22 eligible employers seeking assistance in arranging for health
10 23 benefits coverage for their employees and the employees'
10 24 dependents.
10 25 Sec. 7. NEW SECTION. 514M.7 ELIGIBILITY REQUIREMENTS.
10 26 1. All of the following are eligible for participation in
10 27 the HIFA health insurance program:
10 28 a. Eligible individuals and their dependents.
10 29 b. The employees of an eligible employer and the
10 30 dependents of such employees.
10 31 c. Eligible state employees and their dependents, in
10 32 accordance with applicable collective bargaining agreements.
10 33 d. Eligible local government employees and their
10 34 dependents.
10 35 2. In order to participate, an eligible employer, the
11 1 state, or the local government shall pay at least sixty
11 2 percent of the individual employee's premium costs or the
11 3 combined premium costs of the individual employee and
11 4 dependents of the employee.
11 5 3. The HIFA health insurance program shall collect
11 6 payments from participating employers and plan enrollees to
11 7 cover the costs of all of the following:
11 8 a. Insurance coverage for enrolled employees and their
11 9 dependents in contribution amounts determined by the board.
11 10 b. Quality assurance, patient care management, and cost=
11 11 containment programs.
11 12 c. Administrative services.
11 13 d. Other health promotion costs.
11 14 4. The HIFA program board shall establish a minimum
11 15 required contribution level, to be paid by participating
11 16 employers toward the aggregate payment in subsection 3. The
11 17 minimum required contribution level to be paid by
11 18 participating employers shall be prorated for employees that
11 19 work less than the number of hours of a full=time equivalent
11 20 employee as determined by the employer. The HIFA health
11 21 insurance program may establish a separate minimum
11 22 contribution level to be paid by employers toward coverage for
11 23 dependents of the employers' enrolled employees.
11 24 5. The HIFA health insurance program shall require
11 25 participating employers to certify that at least seventy=five
11 26 percent of their employees that work thirty hours or more per
11 27 week and who do not have other creditable coverage are
11 28 enrolled in the HIFA health insurance program and that the
11 29 employer group otherwise meets the minimum participation
11 30 requirements.
11 31 6. The HIFA health insurance program shall reduce the
11 32 payment amounts for plan enrollees eligible for a subsidy
11 33 pursuant to section 514M.9 accordingly. The employer shall
11 34 pass along any subsidy received to the enrollee up to the
11 35 amount of payments made by the plan enrollee.
12 1 7. The HIFA health insurance program may establish other
12 2 criteria for participation in the program.
12 3 8. The HIFA health insurance program may limit the number
12 4 of participating employers in the program.
12 5 9. The HIFA health insurance program may allow eligible
12 6 individuals and their dependents to purchase insurance under
12 7 the program in accordance with this subsection.
12 8 a. The HIFA health insurance program may establish
12 9 contracts and other reporting forms and procedures necessary
12 10 for the efficient administration of individual contracts.
12 11 b. The HIFA health insurance program shall collect
12 12 payments from eligible individuals participating in the HIFA
12 13 health insurance program to cover the costs of all of the
12 14 following:
12 15 (1) Insurance coverage for eligible individuals and their
12 16 dependents in contribution amounts determined by the board.
12 17 (2) Quality assurance, patient care management, and cost=
12 18 containment programs.
12 19 (3) Administrative services.
12 20 (4) Other health promotion costs.
12 21 c. The HIFA health insurance program shall reduce the
12 22 payment amounts for individuals eligible for a subsidy
12 23 pursuant to section 514M.9 accordingly.
12 24 d. The HIFA health insurance program may require that
12 25 eligible individuals certify that all their dependents are
12 26 enrolled in the HIFA health insurance program or are covered
12 27 by another creditable plan.
12 28 e. The HIFA health insurance program may require an
12 29 eligible individual who is currently employed by an eligible
12 30 employer that does not offer health insurance to certify that
12 31 the current employer did not provide access to an employer=
12 32 sponsored benefits plan in the twelve=month period immediately
12 33 preceding the eligible individual's application.
12 34 f. The HIFA health insurance program may limit the number
12 35 of individual plan enrollees.
13 1 g. The HIFA health insurance program may establish other
13 2 criteria for participation of individuals in the insurance
13 3 program.
13 4 Sec. 8. NEW SECTION. 514M.8 FACILITATION OF ENROLLMENT
13 5 IN HIFA HEALTH INSURANCE PROGRAM.
13 6 The department shall perform, at a minimum, all of the
13 7 following functions to facilitate enrollment in the insurance
13 8 program:
13 9 1. Publicize the availability of HIFA health insurance to
13 10 employers, self=employed individuals, and others eligible to
13 11 enroll in the program.
13 12 2. Screen all eligible individuals and employees for
13 13 eligibility for subsidies pursuant to section 514M.9.
13 14 3. Promote quality improvement, patient care management,
13 15 and cost=containment programs as part of the insurance
13 16 program.
13 17 Sec. 9. NEW SECTION. 514M.9 SUBSIDIES.
13 18 1. The HIFA health insurance program shall establish
13 19 sliding=scale subsidies for the purchase of HIFA health
13 20 insurance by an individual or employee whose income is at or
13 21 below three hundred percent of the federal poverty guidelines
13 22 and who is not eligible for any other state or federally
13 23 funded program. The HIFA health insurance program may also
13 24 establish sliding=scale subsidies for the purchase of
13 25 employer=sponsored health coverage by an employee of an
13 26 employer with more than fifty employees, whose income is under
13 27 three hundred percent of the federal poverty guidelines and
13 28 who is not eligible for any other state or federally funded
13 29 program.
13 30 2. Subsidies shall be limited by the amount of available
13 31 funding.
13 32 3. The HIFA health insurance program may limit the amount
13 33 of the subsidy to individual plan enrollees to forty percent
13 34 of the payment.
13 35 Sec. 10. NEW SECTION. 514M.10 INSURANCE CARRIERS.
14 1 To qualify as a health insurance carrier for HIFA health
14 2 insurance, a health insurance carrier shall do all of the
14 3 following:
14 4 1. Provide the comprehensive health services and benefits
14 5 as determined by the board, including a standard benefit
14 6 package that meets the requirements for mandated coverage for
14 7 specific health services, specific diseases, and for certain
14 8 providers of health services under this title, and any
14 9 supplemental benefits as approved by the board.
14 10 2. Ensure all of the following:
14 11 a. That providers contracting with a health insurance
14 12 carrier contracted to provide coverage to plan enrollees do
14 13 not refuse to provide services to a plan enrollee on the basis
14 14 of health status, medical condition, previous insurance
14 15 status, race, color, creed, age, national origin, citizenship
14 16 status, gender, sexual orientation, disability, or marital
14 17 status. This paragraph shall not be construed to require a
14 18 provider to furnish medical services that are not within the
14 19 scope of that provider's license.
14 20 b. That providers contracting with a health insurance
14 21 carrier contracted to provide coverage to plan enrollees are
14 22 reimbursed at the negotiated reimbursement rates between the
14 23 carrier and its provider network.
14 24 c. That premiums are set utilizing a modified community
14 25 rating.
14 26 Sec. 11. NEW SECTION. 514M.11 SAVINGS OFFSET PAYMENTS.
14 27 1. The board shall determine, annually, not later than
14 28 April 30, the aggregate measurable cost savings, including any
14 29 reduction or avoidance of bad debt and charity care costs to
14 30 health care providers in the state as a result of the
14 31 operation of the HIFA health insurance program.
14 32 2. For the purpose of providing funds necessary to provide
14 33 subsidies pursuant to section 514M.9, and to support the Iowa
14 34 quality forum pursuant to section 514M.13, the board shall
14 35 establish a savings offset amount to be paid by health
15 1 insurance carriers, employee benefit excess insurance
15 2 carriers, and third=party administrators, not including
15 3 carriers and third=party administrators with respect to
15 4 accidental injury, specified disease, hospital indemnity,
15 5 dental, vision, disability, income, long=term care, Medicare
15 6 supplemental, or other limited benefit health insurance,
15 7 annually at a rate that may not exceed savings resulting from
15 8 decreasing rates of growth in bad debt and charity care costs.
15 9 Payment of the savings offset shall begin January 1, 2006.
15 10 The savings offset amount as determined by the board is the
15 11 determining factor for inclusion of savings offset payments in
15 12 premiums through rate=setting review by the insurance division
15 13 of the department of commerce. Savings offset payments must
15 14 be made quarterly and are due not less than thirty days after
15 15 written notice to the health insurance carriers, employee
15 16 benefit excess insurance carriers, and third=party
15 17 administrators.
15 18 3. Each health insurance carrier, employee benefit excess
15 19 insurance carrier, and third=party administrator shall pay a
15 20 savings offset in an amount not to exceed four percent of
15 21 annual health insurance premiums and employee benefit excess
15 22 insurance premiums on policies issued pursuant to the laws of
15 23 this state that insure residents of this state. The savings
15 24 offset payment shall not exceed savings resulting from
15 25 decreasing rates of growth in bad debt and charity care costs.
15 26 The savings offset payment applies to premiums paid on or
15 27 after July 1, 2005. Savings offset payments shall reflect
15 28 aggregate measurable cost savings, including any reduction or
15 29 avoidance of bad debt and charity care costs to health care
15 30 providers in this state, as a result of the operation of the
15 31 HIFA health insurance program as determined by the board. A
15 32 health insurance carrier or employee benefit excess insurance
15 33 carrier shall not be required to pay a savings offset payment
15 34 on policies or contracts insuring federal employees.
15 35 4. The board shall make reasonable efforts to ensure that
16 1 premium revenue, or claims plus any administrative expenses
16 2 and fees with respect to third=party administrators, is
16 3 counted only once with respect to any savings offset payment.
16 4 For that purpose, the board shall require each health
16 5 insurance carrier to include in its premium revenue gross of
16 6 reinsurance ceded. The board shall allow a health insurance
16 7 carrier to exclude from its gross premium revenue reinsurance
16 8 premiums that have been counted by the primary insurer for the
16 9 purpose of determining its savings offset payment under this
16 10 subsection. The board shall allow each employee benefit
16 11 excess insurance carrier to exclude from its gross premium
16 12 revenue the amount of claims that have been counted by a
16 13 third=party administrator for the purpose of determining its
16 14 savings offset payment under this subsection. The board may
16 15 verify each health insurance carrier's, employee benefit
16 16 excess insurance carrier's, and third=party administrator's
16 17 savings offset payment based on annual statements and other
16 18 reports determined to be necessary by the board.
16 19 5. The commissioner of insurance may suspend or revoke,
16 20 after notice and hearing, the certificate of authority to
16 21 transact insurance in this state of any health insurance
16 22 carrier or the license of any third=party administrator to
16 23 operate in this state that fails to pay a savings offset
16 24 payment. In addition, the commissioner may assess civil
16 25 penalties against any health insurance carrier, employee
16 26 benefit excess insurance carrier, or third=party administrator
16 27 that fails to pay a savings offset payment or may take any
16 28 other enforcement action authorized to collect any unpaid
16 29 savings offset payments.
16 30 6. On an annual basis no later than April 30 of each year,
16 31 the board shall prospectively determine the savings offset to
16 32 be applied during each twelve=month period. Annual offset
16 33 payments shall be reconciled to determine whether unused
16 34 payments may be returned to health insurance carriers,
16 35 employee benefit excess insurance carriers, and third=party
17 1 administrators according to a formula developed by the board.
17 2 Savings offset payments shall be used solely to fund the
17 3 subsidies authorized by section 514M.9 and to support the Iowa
17 4 quality forum established in section 514M.13 and may not
17 5 exceed savings from reductions in growth of bad debt and
17 6 charity care.
17 7 7. In accordance with the requirements of this subsection,
17 8 every health insurance carrier and health care provider shall
17 9 demonstrate that best efforts have been made to ensure that a
17 10 carrier has recovered savings offset payments made pursuant to
17 11 this section through negotiated reimbursement rates that
17 12 reflect health care providers' reductions or stabilization in
17 13 the cost of bad debt and charity care as a result of the
17 14 operation of HIFA health insurance.
17 15 a. A health insurance carrier shall use best efforts to
17 16 ensure health insurance premiums reflect any such recovery of
17 17 savings offset payments as those savings offset payments are
17 18 reflected through incurred claims experience.
17 19 b. During any negotiation with a health insurance carrier
17 20 relating to a health care provider's reimbursement agreement
17 21 with that carrier, a health care provider shall provide data
17 22 relating to any reduction or avoidance of bad debt and charity
17 23 care costs to health care providers in this state as a result
17 24 of the operation of the HIFA health insurance program.
17 25 8. The following reports are required in accordance with
17 26 this subsection:
17 27 a. On a quarterly basis, beginning with the first quarter
17 28 after the HIFA health insurance program begins offering
17 29 coverage, the board shall collect and report on the following:
17 30 (1) The total enrollment in the HIFA health insurance
17 31 program, including the number of enrollees previously
17 32 underinsured or uninsured, the number of enrollees previously
17 33 insured, the number of individual enrollees, the number of
17 34 enrollees enrolled through small employers, the number of
17 35 enrollees enrolled through the state of Iowa, and the number
18 1 of enrollees enrolled through local governments.
18 2 (2) The total number of enrollees covered in health plans
18 3 through large employers and self=insured employers.
18 4 (3) The number of employers, both small employers and
18 5 large employers, who have ceased offering health insurance or
18 6 contributing to the cost of health insurance for employees or
18 7 who have begun offering coverage on a self=insured basis.
18 8 (4) The number of employers, both small employers and
18 9 large employers, who have begun to offer health insurance or
18 10 contribute to the cost of health insurance premiums for their
18 11 employees.
18 12 (5) The number of new participating employers in the HIFA
18 13 health insurance program.
18 14 (6) The number of employers ceasing to offer coverage
18 15 through the HIFA health insurance program.
18 16 (7) The duration of employers' participation in the HIFA
18 17 health insurance program.
18 18 (8) A comparison of actual enrollees in the HIFA health
18 19 insurance program to the projected enrollees.
18 20 b. The board shall establish the total health care
18 21 spending in the state for the base year beginning July 1,
18 22 2003, and shall annually determine, in collaboration with the
18 23 commissioner of insurance, appropriate actuarially supported
18 24 trend factors that reflect savings consistent with subsection
18 25 1 and compare rates of spending growth to the base year of
18 26 2003. The board shall collect on an annual basis, in
18 27 consultation with the commissioner, information about the
18 28 total cost to the state's health care providers of bad debt
18 29 and charity care beginning with the base year of 2003. This
18 30 information may be compiled through mechanisms including, but
18 31 not limited to, standard reporting or statistically accurate
18 32 surveys of providers and practitioners. The board shall
18 33 utilize existing data on file with state agencies or other
18 34 organizations to minimize duplication. The comparisons to the
18 35 base year shall be reported beginning April 30, 2005, and
19 1 annually thereafter.
19 2 c. Health insurance carriers and health care providers
19 3 shall report annually, beginning July 1, 2006, and each July 1
19 4 thereafter, information regarding the experience of the prior
19 5 twelve=month period on the efforts undertaken by the carrier
19 6 and provider to recover savings offset payments, as reflected
19 7 in reimbursement rates, through a reduction or stabilization
19 8 in bad debt and charity care costs as a result of the
19 9 operation of the HIFA health insurance program. The board
19 10 shall determine the appropriate format for the report and
19 11 utilize existing data on file with state agencies or other
19 12 organizations to minimize duplication. The report shall be
19 13 submitted to the board. Using the information submitted by
19 14 carriers and providers, the board shall submit a summary of
19 15 that information by October 1, 2006, and annually thereafter
19 16 to the commissioner of insurance, the governor, and the
19 17 general assembly.
19 18 9. The claims experience used to determine any filed
19 19 premiums or rating formula shall reasonably reflect, in
19 20 accordance with accepted actuarial standards, known changes
19 21 and offsets in payments by the carrier to health care
19 22 providers in this state, including any reduction or avoidance
19 23 of bad debt and charity care costs to health care providers in
19 24 this state as a result of the operation of the HIFA health
19 25 insurance program.
19 26 Sec. 12. NEW SECTION. 514M.12 HIFA PROGRAM FUND.
19 27 1. A HIFA program fund is created in the state treasury
19 28 under the authority of the department for deposit of any funds
19 29 for initial operating expenses, payments made by employers and
19 30 individuals, any savings offset payments made pursuant to
19 31 section 514M.11, and any funds received from any public or
19 32 private source.
19 33 2. Moneys deposited in the fund shall be used only for the
19 34 purposes of the HIFA program as specified in this chapter.
19 35 3. The fund shall be separate from the general fund of the
20 1 state and shall not be considered part of the general fund of
20 2 the state. The moneys in the fund shall not be considered
20 3 revenue of the state, but rather shall be funds of the HIFA
20 4 program. The moneys deposited in the fund are not subject to
20 5 section 8.33 and shall not be transferred, used, obligated,
20 6 appropriated, or otherwise encumbered, except to provide for
20 7 the purposes of this chapter. Notwithstanding section 12C.7,
20 8 subsection 2, interest or earnings on moneys deposited in the
20 9 fund shall be credited to the fund.
20 10 4. The department shall adopt rules pursuant to chapter
20 11 17A to administer the fund.
20 12 5. The treasurer of state shall provide a quarterly report
20 13 of fund activities and balances to the board.
20 14 Sec. 13. NEW SECTION. 514M.13 IOWA QUALITY FORUM.
20 15 1. The Iowa quality forum is established within the HIFA
20 16 program. The forum shall be governed by the HIFA program
20 17 board with advice from the Iowa quality forum advisory council
20 18 pursuant to section 514M.14. The forum shall be funded, at
20 19 least in part, through the savings offset payments made
20 20 pursuant to section 514M.11.
20 21 2. The forum shall do all of the following:
20 22 a. Collect and disseminate research regarding health care
20 23 quality, evidence=based medicine, and patient safety to
20 24 promote best practices.
20 25 b. Adopt a set of measures to evaluate and compare health
20 26 care quality and provider performance. The measures must be
20 27 adopted with guidance from the advisory council pursuant to
20 28 section 514M.14.
20 29 c. Coordinate the collection of health care quality data
20 30 in the state. The forum shall work with entities that collect
20 31 health care data to minimize duplication and to minimize the
20 32 burden on providers of data.
20 33 d. Provide oversight for a retrospective drug utilization
20 34 review and quality assessment program.
20 35 e. Work collaboratively with health care providers, health
21 1 insurance carriers, and others to report in useable formats,
21 2 comparative health care quality information to consumers,
21 3 purchasers, providers, insurers, and policymakers. The forum
21 4 shall produce annual quality reports.
21 5 f. Conduct education campaigns to help health care
21 6 consumers make informed decisions and engage in healthy
21 7 lifestyles.
21 8 g. Adopt plans to provide medication therapy management by
21 9 pharmacy providers targeted to individuals who have multiple
21 10 chronic conditions, use multiple prescriptions, and are likely
21 11 to incur high drug expenses in order to ensure appropriate use
21 12 of prescription drugs to improve therapeutic outcomes and
21 13 reduce adverse drug reactions.
21 14 h. Encourage the adoption of electronic technology and
21 15 assist health care practitioners to implement electronic
21 16 systems for medical records and submission of claims. The
21 17 assistance may include, but is not limited to, practitioner
21 18 education, identification, or establishment of low=interest
21 19 financing options for hardware and software and system
21 20 implementation support.
21 21 i. Make recommendations for inclusion in the state health
21 22 plan developed pursuant to section 514M.16.
21 23 j. Submit an annual report to the governor and the general
21 24 assembly and make the report available to the public.
21 25 Sec. 14. NEW SECTION. 514M.14 IOWA QUALITY FORUM
21 26 ADVISORY COUNCIL.
21 27 1. An Iowa quality forum advisory council is established
21 28 to advise the forum. The council shall consist of all of the
21 29 following voting members, appointed by the governor, subject
21 30 to confirmation by the senate:
21 31 a. One member who is a physician.
21 32 b. One member who is a health care economist.
21 33 c. One member who is a pharmacist.
21 34 d. One member who represents hospitals.
21 35 e. One member who is a representative of the university of
22 1 Iowa college of public health.
22 2 f. One member who is a representative of a private
22 3 employer with not more than fifty employees.
22 4 g. One member who is a representative of a private
22 5 employer with more than one thousand employees.
22 6 h. One member who is a representative of organized labor.
22 7 i. One member who is a representative of a consumer health
22 8 advocacy group.
22 9 j. The director of public health, or the director's
22 10 designee.
22 11 2. The commissioner of insurance shall serve as an ex
22 12 officio nonvoting member of the advisory council.
22 13 3. All members of the advisory council with the exception
22 14 of the director of public health and the commissioner of
22 15 insurance are subject to the following:
22 16 a. Shall serve five=year staggered terms as designated by
22 17 the governor.
22 18 b. Shall be subject to chapter 69 with regard to the
22 19 filling of vacancies, membership terms, payment of
22 20 compensation and expenses, and removal.
22 21 c. Are entitled to receive reimbursement of actual
22 22 expenses incurred in the discharge of their duties and are
22 23 also eligible to receive compensation as provided in section
22 24 7E.6.
22 25 d. Shall not serve more than two consecutive terms.
22 26 4. The advisory council shall annually choose one of its
22 27 voting members to serve as chairperson for a one=year term.
22 28 5. The advisory council shall meet at least four times
22 29 annually and may meet at other times at the call of the
22 30 chairperson. Meetings of the council are public proceedings.
22 31 6. The advisory council shall do all of the following:
22 32 a. Convene a group of health care providers to provide
22 33 input and advice to the council.
22 34 b. Provide expertise in health care quality to assist the
22 35 board.
23 1 c. Advise and support the forum by doing all of the
23 2 following:
23 3 (1) Establishing and monitoring, with the HIFA program, an
23 4 annual work plan for the forum.
23 5 (2) Providing guidance in the adoption of quality and
23 6 performance measures.
23 7 (3) Serving as a liaison between the provider group
23 8 established in paragraph "a" and the forum.
23 9 (4) Conducting public hearings and meetings.
23 10 (5) Reviewing consumer education materials developed by
23 11 the forum.
23 12 d. Assist the board in selecting the nationally recognized
23 13 functional health assessment.
23 14 e. Make recommendations regarding quality assurance and
23 15 quality improvement priorities for inclusion in the state
23 16 health plan described in section 514M.16.
23 17 f. Serve as a liaison between the forum and other
23 18 organizations working in the field of health care quality.
23 19 Sec. 15. NEW SECTION. 514M.15 HIFA HIGH=RISK POOL.
23 20 1. A plan enrollee shall be included in the HIFA high=risk
23 21 pool if the total cost of health care services for the
23 22 enrollee exceeds fifty thousand dollars in any twelve=month
23 23 period.
23 24 2. The HIFA program shall develop appropriate patient care
23 25 management protocols, develop procedures for implementing
23 26 those protocols, and determine the manner in which patient
23 27 care management shall be provided to plan enrollees in the
23 28 HIFA high=risk pool. Patient care management shall be
23 29 provided by appropriate individual health care professionals
23 30 under the HIFA program. The HIFA program shall include
23 31 patient care management in its contract with participating
23 32 health insurance carriers for HIFA high=risk pool enrollees
23 33 pursuant to this section, contract separately with another
23 34 entity for patient care management services, or provide
23 35 patient care management services directly through the HIFA
24 1 program.
24 2 3. The HIFA program shall submit a report to the governor
24 3 and the general assembly, no later than January 1, 2006,
24 4 outlining the patient care management protocols, procedures,
24 5 and delivery mechanisms used to provide patient care
24 6 management services to HIFA high=risk pool enrollees and the
24 7 assessment tool used to measure individual patient care
24 8 management activities. The report shall also include the
24 9 number of plan enrollees in the high=risk pool, the types of
24 10 diagnoses managed within the high=risk pool, the claims
24 11 experience within the high=risk pool, and the number and type
24 12 of claims exceeding fifty thousand dollars for enrollees in
24 13 the high=risk pool and for all enrollees in the HIFA health
24 14 insurance program.
24 15 4. On or before October 1, 2008, the HIFA program shall
24 16 evaluate the impact of HIFA health insurance on average health
24 17 insurance premium rates in this state and on the rate of
24 18 uninsured individuals in this state and compare the trends in
24 19 those rates to the trends in the average premium rates and
24 20 average rates of uninsured individuals for the states that
24 21 have established a statewide high=risk pool as of July 1,
24 22 2004. The board shall submit the evaluation of the impact of
24 23 HIFA health insurance in this state in comparison to states
24 24 with high=risk pools to the governor and the general assembly
24 25 by January 1, 2009. If the trend in average premium rates in
24 26 this state and rate of uninsured individuals exceeds the trend
24 27 for the average among the states with high=risk pools, the
24 28 board shall submit legislation on January 1, 2009, that
24 29 proposes to establish a statewide high=risk pool in this state
24 30 consistent with the characteristics of high=risk pools
24 31 operating in other states.
24 32 Sec. 16. NEW SECTION. 514M.16 STATE HEALTH PLANNING.
24 33 1. The governor or the governor's designee shall do all of
24 34 the following:
24 35 a. Develop and issue a biennial state health plan. The
25 1 first plan shall be issued by May 2005.
25 2 b. Make an annual report to the public assessing the
25 3 progress toward meeting goals of the plan and provide any
25 4 updates, as necessary, to the plan.
25 5 c. Issue an annual statewide health expenditure budget
25 6 report that shall serve as the basis for establishing
25 7 priorities within the plan.
25 8 2. a. The state health plan issued pursuant to subsection
25 9 1 shall establish a comprehensive, coordinated approach to the
25 10 development of health care facilities and resources in the
25 11 state based on statewide cost, quality, and access goals and
25 12 strategies to ensure access to affordable health care,
25 13 maintain a rational system of health care, and promote the
25 14 development of the health care workforce.
25 15 b. In developing the plan, the governor shall, at a
25 16 minimum, seek input from the Iowa quality forum, the Iowa
25 17 quality forum advisory council, and other appropriate agencies
25 18 and organizations.
25 19 3. The plan shall do all of the following:
25 20 a. Assess health care cost, quality, and access in the
25 21 state.
25 22 b. Develop benchmarks to measure cost, quality, and access
25 23 goals and report on progress toward meeting those goals.
25 24 c. Establish and set annual priorities among health care
25 25 cost, quality, and access goals.
25 26 d. Outline strategies to do all of the following:
25 27 (1) Promote health systems change.
25 28 (2) Address the factors influencing health care cost
25 29 increases.
25 30 (3) Address the major threats to public health and safety
25 31 in the state, including, but not limited to, lung disease,
25 32 diabetes, cancer, and heart disease.
25 33 e. Provide recommendations to help purchasers and
25 34 providers make decisions that improve public health and build
25 35 an affordable, high=quality health care system.
26 1 Sec. 17. NEW SECTION. 514M.17 RULES.
26 2 The commissioner of insurance shall adopt rules, pursuant
26 3 to chapter 17A, as necessary to administer this chapter.
26 4 Sec. 18. IMPLEMENTATION COSTS. The Iowa department of
26 5 public health shall work with the commissioner of insurance to
26 6 seek funding through the federal government, a private
26 7 foundation, or other appropriate source to defray the initial
26 8 costs to implement the provisions of this Act, including but
26 9 not limited to the initial subsidy provisions.
26 10 EXPLANATION
26 11 This bill establishes a healthy Iowa for all (HIFA) program
26 12 which includes the HIFA health insurance program, the HIFA
26 13 program fund, the Iowa quality forum, the HIFA high=risk pool,
26 14 and state health planning.
26 15 The bill establishes the HIFA program within the Iowa
26 16 department of public health to provide access to health care
26 17 coverage to eligible employers, including the self=employed,
26 18 their employees and dependents, state employees and their
26 19 dependents, local government employees and their dependents,
26 20 and individuals and their dependents.
26 21 The HIFA board consists of five voting members appointed by
26 22 the governor, subject to confirmation by the senate, and ex
26 23 officio members including the director of public health, the
26 24 director of human services, the commissioner of insurance, two
26 25 members of the senate, and two members of the house of
26 26 representatives.
26 27 The bill provides the duties of the department and the
26 28 board.
26 29 The HIFA health insurance program is to provide health
26 30 benefits coverage through health insurance carriers that apply
26 31 to the board and meet the qualifications specified. The bill
26 32 provides that if a sufficient number of health insurance
26 33 carriers do not apply to offer and deliver health insurance,
26 34 the board may propose the establishment of a nonprofit health
26 35 care plan or may propose the expansion of an existing public
27 1 plan. The health insurance program is to select health
27 2 insurance carriers through a request for proposals process.
27 3 The bill provides eligibility provisions and requirements
27 4 of employers and individuals participating in the program,
27 5 including contribution levels and employee participation.
27 6 The bill provides subsidies on a sliding scale for
27 7 individual and employee enrollees whose income is at or below
27 8 300 percent of the federal poverty guidelines.
27 9 The bill provides for the financing of the HIFA program
27 10 through the collection of savings offset payments made by
27 11 insurance carriers, employee benefit excess insurance
27 12 carriers, and third=party administrators based on savings in
27 13 charity care, bad debt, and savings due to cost controls
27 14 resulting from the HIFA health insurance program. The bill
27 15 provides a process for identifying the savings and the amount
27 16 of the offset payments.
27 17 The bill establishes a HIFA program fund. The bill also
27 18 establishes an Iowa quality forum to collect and review health
27 19 care quality data, to educate consumers regarding health care
27 20 and healthy lifestyles, and to make recommendations to the
27 21 governor regarding the state health plan. An Iowa quality
27 22 forum advisory council is established to advise the forum.
27 23 The bill provides for the establishment of a high=risk pool
27 24 for enrollees whose total annual health costs exceed $50,000.
27 25 The bill provides for state health planning through the
27 26 development and issuance of a biennial state health plan.
27 27 The bill directs the Iowa department of public health to
27 28 work with the commissioner of insurance in seeking federal,
27 29 foundation, or other funding to defray the bill's initial
27 30 implementation costs.
27 31 LSB 6312HH 80
27 32 pf/gg/14.4