Senate File 2092 - Introduced SENATE FILE 2092 BY HATCH , DEARDEN , KIBBIE , BEALL , RAGAN , BOLKCOM , GRONSTAL , FRAISE , BLACK , JOCHUM , STEWART , SCHMITZ , DANIELSON , DOTZLER , HECKROTH , WARNSTADT , HORN , SENG , QUIRMBACH , McCOY , WILHELM , HOGG , DVORSKY , KREIMAN , SCHOENJAHN , and SODDERS A BILL FOR An Act relating to health reform in Iowa by creating an 1 IowaCare plus program and an Iowa choice exchange. 2 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 3 TLSB 5392XS (19) 83 pf:av/rj

S.F. 2092 DIVISION I 1 IOWACARE PLUS PROGRAM 2 Section 1. NEW SECTION . 217A.1 Title. 3 This chapter shall be known and may be cited as the “IowaCare 4 Plus Act” . 5 Sec. 2. NEW SECTION . 217A.2 Definitions. 6 As used in this chapter, unless the context otherwise 7 requires: 8 1. “Department” means the department of human services. 9 2. “Director” means the director of human services. 10 3. “Eligible individual” means an individual who meets the 11 eligibility requirements in section 217A.4. 12 4. “Full benefit recipient rate” means the rate paid to 13 a provider for an adult who is eligible for full medical 14 assistance benefits pursuant to chapter 249A under any category 15 of eligibility. 16 5. “Fund” means the IowaCare plus trust fund created in 17 section 217A.8. 18 6. “Iowa Medicaid enterprise” means the Iowa Medicaid 19 enterprise as defined in section 249J.3. 20 7. “IowaCare plus member” or “member” means an IowaCare plus 21 member with active eligibility status. 22 8. “Premium assistance payment” means a premium payment 23 made on behalf of a member in the program, under a schedule 24 established by the department. 25 9. “Program” means the IowaCare plus program created in this 26 chapter. 27 Sec. 3. NEW SECTION . 217A.3 Purposes —— principles —— 28 administration. 29 1. An IowaCare plus program shall be created to do all of 30 the following: 31 a. To improve the health of adults in the state. 32 b. To improve the quality of health care and access to 33 health care in the state. 34 c. To provide health care coverage to adults in the state 35 -1- LSB 5392XS (19) 83 pf:av/rj 1/ 27

S.F. 2092 who would otherwise be uninsured. 1 d. To increase the range of health care coverage options 2 available to Iowans. 3 e. To slow the growth of per capita health care spending. 4 f. To serve as a model for reforming the health care 5 delivery system. 6 2. The IowaCare plus program shall be established and 7 administered in accordance with the following guiding health 8 care coverage reform principles: 9 a. Health care coverage should be accessible. 10 b. Health care coverage should be continuous. 11 c. Health care coverage should be affordable to individuals 12 and families. 13 d. The provision of health care coverage should be 14 sustainable for Iowa. 15 e. Health care coverage should enhance health and well-being 16 by promoting access to high-quality care that is effective, 17 efficient, safe, timely, patient-centered, and equitable. 18 3. a. The program shall be administered by the Iowa 19 Medicaid enterprise. 20 b. The program shall be administered consistent with the 21 Iowa medical assistance program. State and federal laws, rules 22 and regulations applicable to the Iowa medical assistance 23 program pursuant to chapter 249A and 42 C.F.R. pts. 430 24 through 456 shall apply to the IowaCare plus program, with the 25 exception of benefits and eligibility provisions inconsistent 26 with sections 217A.4 and 217A.5. 27 c. The provisions of this chapter shall not be construed, 28 are not intended as, and shall not imply a grant of entitlement 29 for services to individuals who are eligible for assistance 30 under this chapter or for utilization of services that do 31 not exist or are not otherwise available on July 1, 2010. 32 Any state obligation to provide services pursuant to this 33 chapter is limited to the extent of the funds appropriated or 34 distributed for the purposes of this chapter. 35 -2- LSB 5392XS (19) 83 pf:av/rj 2/ 27

S.F. 2092 d. All agencies and offices of the state, or of any 1 political subdivision of the state, shall fully cooperate with 2 the Iowa Medicaid enterprise and the department in carrying out 3 the purposes of this section. 4 Sec. 4. NEW SECTION . 217A.4 IowaCare plus —— eligibility. 5 1. Except as otherwise provided in this chapter, an 6 individual nineteen through sixty-four years of age shall be 7 eligible for the membership benefits described in section 8 217A.5 when provided through the regional provider network as 9 described in section 217A.6, if the individual meets all of the 10 following conditions: 11 a. The individual is not eligible for health care coverage 12 under any other public program or through group or individual 13 health insurance, or health care coverage offered through group 14 or individual health insurance is not affordable. 15 b. The individual has a family income above two hundred 16 percent but not in excess of four hundred percent of the 17 federal poverty level as defined by the most recently revised 18 poverty income guidelines published by the United States 19 department of health and human services. 20 c. The individual’s or family member’s employer has not 21 provided health insurance coverage in the last six months for 22 which the individual is eligible and for which the employer 23 covers at least twenty percent of the annual premium cost of a 24 family health insurance plan or at least thirty-three percent 25 of an individual health insurance plan. 26 d. The individual has not accepted a financial incentive 27 from the individual’s employer to decline the employer’s 28 subsidized health insurance plan. 29 e. The individual fulfills all other conditions of 30 participation described in this chapter, including requirements 31 relating to personal financial responsibility. 32 2. Following initial enrollment, an IowaCare plus member 33 shall reenroll annually by the last day of the month preceding 34 the month in which the member initially enrolled. The 35 -3- LSB 5392XS (19) 83 pf:av/rj 3/ 27

S.F. 2092 department may provide a process for automatic reenrollment of 1 members. 2 3. The department shall develop a plan for outreach and 3 education that is designed to ensure that Iowans are informed 4 about the program and are encouraged to enroll in the program. 5 The outreach and education plan shall include a focus on 6 targeting populations that are underserved by the health care 7 delivery system. 8 Sec. 5. NEW SECTION . 217A.5 IowaCare plus —— benefits. 9 1. IowaCare plus members shall be eligible for all of the 10 following benefits: 11 a. Inpatient hospital procedures described in the 12 diagnostic-related group codes or other applicable inpatient 13 hospital reimbursement methods designated by the department. 14 b. Outpatient hospital services described in the ambulatory 15 patient groupings or non-inpatient services designated by the 16 department. 17 c. Physician and advanced registered nurse practitioner 18 services described in the current procedural terminology codes 19 specified by the department. 20 d. Dental services described in the dental codes specified 21 by the department. 22 e. Limited pharmacy benefits as specified by the department. 23 f. Primary care coordination. 24 2. a. Each member shall receive a comprehensive medical 25 examination annually. The department may implement a 26 web-based health risk assessment for members that may include 27 facilitation, if deemed to be cost-effective to the program. 28 b. Refusal of a member to participate in a comprehensive 29 medical examination or any health risk assessment implemented 30 by the department shall not be a basis for ineligibility for or 31 disenrollment from the program. 32 Sec. 6. NEW SECTION . 217A.6 Regional provider network. 33 1. The department shall establish a regional provider 34 network and shall enter into contracts or 28E agreements with 35 -4- LSB 5392XS (19) 83 pf:av/rj 4/ 27

S.F. 2092 providers specified for participation in the network. The 1 regional provider network shall include all of the following: 2 a. Providers designated by the department who are part of 3 the Iowa collaborative safety net provider network established 4 pursuant to section 135.153. 5 b. The publicly owned acute care teaching hospital located 6 in a county with a population over three hundred fifty thousand 7 and the university of Iowa hospitals and clinics, that are part 8 of the expansion population provider network as specified in 9 section 249J.7. 10 c. Hospitals designated by the department. 11 d. Other health care providers designated by the department 12 as necessary to provide regional access to the benefits 13 specified under section 217A.5. 14 2. The department may designate specific providers within a 15 region for the provision of primary, specialty, and tertiary 16 care. 17 3. All members shall receive benefits described in section 18 217A.5 through a medical home. The department shall adopt 19 rules pursuant to chapter 17A, in collaboration with the 20 medical home advisory council created pursuant to section 21 135.159, specifying requirements for medical homes including 22 certification, with which participating providers shall comply, 23 as appropriate. 24 4. The department may develop a payment rate methodology to 25 support the medical home requirement. 26 Sec. 7. NEW SECTION . 217A.7 Financial participation. 27 1. The department shall adopt rules pursuant to chapter 28 17A to establish all cost-sharing requirements of the program, 29 including any premiums, deductibles, and copayment amounts. 30 Cost sharing shall be based on a sliding scale and any 31 cost-sharing requirements shall meet the percentage standards 32 for affordability established pursuant to 2009 Iowa Acts, 33 chapter 118, section 1, subsection 4, paragraph “c” . 34 2. Each IowaCare plus member whose family income exceeds 35 -5- LSB 5392XS (19) 83 pf:av/rj 5/ 27

S.F. 2092 two hundred percent but does not exceed three hundred percent 1 of the federal poverty level as defined by the most recently 2 revised poverty income guidelines published by the United 3 States department of health and human services may be eligible 4 for a premium assistance payment as specified by rule of the 5 department. 6 3. Each IowaCare plus member whose family income exceeds 7 three hundred percent but does not exceed four hundred percent 8 of the federal poverty level as defined by the most recently 9 revised poverty income guidelines published by the United 10 States department of health and human services shall pay the 11 entire amount of cost sharing required by the program and is 12 not eligible for a premium assistance payment provided through 13 the program. 14 4. If an eligible individual has access to health care 15 coverage through the individual’s employer, but such health 16 care coverage is not affordable, the program may pay the 17 employee share of the premium up to the amount that the 18 program would subsidize the member through the program, if 19 cost-effective to the program. 20 5. Premiums collected pursuant to this section shall be 21 deposited in the IowaCare plus trust fund created in section 22 217A.8. 23 Sec. 8. NEW SECTION . 217A.8 IowaCare plus trust fund. 24 1. An IowaCare plus trust fund is created in the state 25 treasury under the authority of the department. Moneys 26 appropriated from the general fund of the state to the fund, 27 moneys collected as premiums pursuant to section 217A.7, and 28 moneys from any other source credited to the fund shall be 29 deposited in the fund. Moneys deposited in or credited to the 30 fund shall be used only as provided in appropriations from the 31 fund for the purpose of the IowaCare plus program. 32 2. The fund shall be separate from the general fund of the 33 state and shall not be considered part of the general fund of 34 the state. The moneys in the fund shall not be considered 35 -6- LSB 5392XS (19) 83 pf:av/rj 6/ 27

S.F. 2092 revenue of the state, but rather shall be moneys of the fund. 1 The moneys in the fund are not subject to section 8.33 and 2 shall not be transferred, used, obligated, appropriated, or 3 otherwise encumbered, except to provide for the purposes of 4 this chapter. Notwithstanding section 12C.7, subsection 2, 5 interest or earnings on moneys deposited in the fund shall be 6 credited to the fund. 7 3. The department shall adopt rules pursuant to chapter 17A 8 to administer the fund. 9 Sec. 9. NEW SECTION . 217A.9 Contingent implementation. 10 Implementation of this chapter is contingent upon the 11 availability of funding as determined by the director and as 12 stipulated in rules. 13 Sec. 10. NEW SECTION . 135.162A Diabetes registry. 14 1. The department shall establish a uniform, statewide 15 registry for the collection of data regarding diabetes. 16 The purposes of the registry are to collect and serve as 17 a repository for data about the prevalence and incidence 18 of diabetes occurring in the population; to assist medical 19 providers in tracking and improving the care of patients 20 with diabetes; to provide a clearinghouse of information for 21 individuals, their families, and providers about diabetes; to 22 make the data available for scientific and medical research; 23 and to assist in making decisions about the allocation of 24 public resources. 25 2. The department shall adopt rules pursuant to chapter 26 17A to administer the registry including the reporting format, 27 the data to be collected, the use of data collected, and 28 confidentiality of and access to the data. 29 3. In addition to the collection of data, the department 30 shall provide training and on-site support for providers to 31 participate in the registry, to change patterns of patient 32 care through use of evidence-based practices by the provider, 33 and to enable involvement by patients in patient education, 34 self-management, and follow-up plans. 35 -7- LSB 5392XS (19) 83 pf:av/rj 7/ 27

S.F. 2092 4. Implementation of this section is contingent upon the 1 availability of funding as determined by the director of public 2 health and stipulated in rules. 3 Sec. 11. Section 249J.7, Code 2009, is amended to read as 4 follows: 5 249J.7 Expansion population provider network. 6 1. a. Expansion population members shall only be eligible 7 to receive expansion population services through a provider 8 included in the expansion population provider network. Except 9 as otherwise provided in this chapter, the expansion population 10 provider network shall be limited to a publicly owned acute 11 care teaching hospital located in a county with a population 12 over three hundred fifty thousand, the university of Iowa 13 hospitals and clinics, and the state hospitals for persons with 14 mental illness designated pursuant to section 226.1 with the 15 exception of the programs at such state hospitals for persons 16 with mental illness that provide substance abuse treatment, 17 serve gero-psychiatric patients, or treat sexually violent 18 predators and a regional provider network utilizing providers 19 that are part of the Iowa collaborative safety net provider 20 network established pursuant to section 135.153, designated by 21 the department to provide primary care to members. 22 b. The regional provider network shall include at least 23 one primary care provider for each county designated to serve 24 expansion population members residing in that county. Payment 25 shall only be made to the county’s designated primary care 26 provider for eligible primary care services provided to a 27 member. The department shall adopt rules pursuant to chapter 28 17A, in collaboration with the medical home advisory council 29 created pursuant to section 135.159, specifying requirements 30 for medical homes including certification, with which regional 31 provider network participating providers shall comply, as 32 appropriate. The department may also designate other private 33 providers and hospitals to participate in the regional provider 34 network, to provide primary and specialty care, subject to the 35 -8- LSB 5392XS (19) 83 pf:av/rj 8/ 27

S.F. 2092 availability of funds . 1 c. Tertiary care shall be provided to eligible expansion 2 population members residing in any county in the state at the 3 university of Iowa hospitals and clinics. 4 d. Once the statutorily specified amount of funding is 5 distributed to the publicly owned acute care teaching hospital 6 located in a county with a population over three hundred fifty 7 thousand, eligible expansion population members may receive 8 primary care services through other primary care providers 9 located in that county as designated by the department. 10 2. Expansion population services provided to expansion 11 population members by providers included in the expansion 12 population provider network shall be payable at the full 13 benefit recipient rates. 14 3. Providers included in the expansion population provider 15 network shall submit clean claims within twenty days of the 16 date of provision of an expansion population service to an 17 expansion population member. 18 4. Unless otherwise prohibited by law, a provider under 19 the expansion population provider network may deny care to 20 an individual who refuses to apply for coverage under the 21 expansion population. 22 5. Notwithstanding the provision of section 347.16, 23 subsection 2, requiring the provision of free care and 24 treatment to the persons described in that subsection, the 25 publicly owned acute care teaching hospital described in 26 subsection 1 may require any sick or injured person seeking 27 care or treatment at that hospital to be subject to financial 28 participation, including but not limited to copayments 29 or premiums, and may deny nonemergent care or treatment 30 to any person who refuses to be subject to such financial 31 participation. 32 6. The department shall utilize certified public 33 expenditures at the university of Iowa hospitals and clinics to 34 maximize the availability of state funding to provide necessary 35 -9- LSB 5392XS (19) 83 pf:av/rj 9/ 27

S.F. 2092 access to both local primary and specialty physician care to 1 expansion population members. The department shall determine, 2 in collaboration with the university of Iowa hospitals and 3 clinics and the Iowa collaborative safety net provider network 4 established pursuant to section 135.153, the maximum amount 5 of expenditures that can be claimed using certified public 6 expenditures by the university of Iowa hospitals and clinics. 7 Based upon the amount determined, any state appropriation of 8 these funds shall be made in equal sums to the university 9 of Iowa college of medicine for reimbursement of physician 10 services provided to expansion population members and to the 11 providers designated to participate in the regional provider 12 network to offset costs incurred in providing eligible services 13 to expansion population members. 14 Sec. 12. Section 263.18, subsection 4, Code 2009, is amended 15 to read as follows: 16 4. The physicians and surgeons on the staff of the 17 university of Iowa hospitals and clinics who care for patients 18 provided for in this section may charge for the medical 19 services provided under such rules, regulations, and plans 20 approved by the state board of regents. However, a physician 21 or surgeon who provides treatment or care for an expansion 22 population member pursuant to chapter 249J shall not charge 23 or only receive any compensation for the treatment or care 24 except the salary or compensation fixed by the state board 25 of regents to be paid from the hospital fund provided in 26 accordance with section 249J.7 . 27 Sec. 13. IOWACARE —— EXTENSION OF WAIVER. The department 28 of human services shall amend the extension proposal for the 29 IowaCare section 1115 demonstration waiver and shall submit 30 applicable state plan amendments under the medical assistance 31 program to provide expansion population services through the 32 expansion population network pursuant to section 249J.7, as 33 amended by this Act, within the budget neutrality cap and 34 subject to availability of state matching funds. 35 -10- LSB 5392XS (19) 83 pf:av/rj 10/ 27

S.F. 2092 DIVISION II 1 IOWA CHOICE EXCHANGE 2 Sec. 14. NEW SECTION . 514M.1 Short title. 3 This chapter shall be known and may be cited as the “Iowa 4 Choice Exchange Act” . 5 Sec. 15. NEW SECTION . 514M.2 Purposes. 6 The purposes of this chapter include but are not limited to 7 the following: 8 1. To provide a portal where uninsured Iowans can receive 9 assistance in obtaining health care coverage. 10 2. To provide an information clearinghouse where all 11 Iowans can obtain information about health care coverage that 12 is available in the state including comparisons of benefits, 13 premiums, and out-of-pocket costs. 14 Sec. 16. NEW SECTION . 514M.3 Definitions. 15 As used in this chapter, unless the context otherwise 16 requires: 17 1. “Board” means the board of directors of the Iowa choice 18 exchange. 19 2. “Carrier” means an insurer providing accident and 20 sickness insurance under chapter 509, 514, or 514A and 21 includes a health maintenance organization established under 22 chapter 514B if payments received by the health maintenance 23 organization are considered premiums pursuant to section 24 514B.31 and are taxed under chapter 432. “Carrier” also 25 includes a corporation which becomes a mutual insurer pursuant 26 to section 514.23 and any other person as defined in section 27 4.1, who is or may become liable for the tax imposed by chapter 28 432. 29 3. “Commissioner” means the commissioner of insurance. 30 4. “Creditable coverage” means health benefits or coverage 31 provided to an individual under any of the following: 32 a. A group health plan. 33 b. Health insurance coverage. 34 c. Part A or part B Medicare pursuant to Tit. XVIII of the 35 -11- LSB 5392XS (19) 83 pf:av/rj 11/ 27

S.F. 2092 federal Social Security Act. 1 d. Medicaid pursuant to Tit. XIX of the federal Social 2 Security Act, other than coverage consisting solely of benefits 3 under section 1928 of that Act. 4 e. 10 U.S.C. ch. 55. 5 f. A health or medical care program provided through the 6 Indian health service or a tribal organization. 7 g. A state health benefits risk pool. 8 h. A health plan offered under 5 U.S.C. ch. 89. 9 i. A public health plan as defined under federal 10 regulations. 11 j. A health benefit plan under section 5(e) of the federal 12 Peace Corps Act, 22 U.S.C. § 2504(e). 13 k. An organized delivery system licensed by the director of 14 public health. 15 l. The hawk-i program authorized by chapter 514I. 16 5. “Director” means the director of revenue. 17 6. “Exchange” means the Iowa choice exchange. 18 7. “Executive director” means the executive director of the 19 Iowa choice exchange. 20 8. a. “Group health plan” means an employee welfare 21 benefit plan as defined in section 3(1) of the federal Employee 22 Retirement Income Security Act of 1974, to the extent that the 23 plan provides medical care including items and services paid 24 for as medical care to employees or their dependents as defined 25 under the terms of the plan directly or through insurance, 26 reimbursement, or otherwise. 27 b. For purposes of this subsection, “medical care” means 28 medical care for which amounts are paid for any of the 29 following: 30 (1) The diagnosis, cure, mitigation, treatment, or 31 prevention of disease, or for the purpose of affecting a 32 structure or function of the body. 33 (2) Transportation primarily for and essential to medical 34 care referred to in subparagraph (1). 35 -12- LSB 5392XS (19) 83 pf:av/rj 12/ 27

S.F. 2092 (3) Insurance covering medical care referred to in 1 subparagraph (1) or (2). 2 c. For purposes of this subsection, the following apply: 3 (1) A plan, fund, or program established or maintained 4 by a partnership which, but for this subsection, would not 5 be an employee welfare benefit plan, shall be treated as an 6 employee welfare benefit plan which is a group health plan to 7 the extent that the plan, fund, or program provides medical 8 care, including items and services paid for as medical care 9 for present or former partners in the partnership or to the 10 dependents of such partners, as defined under the terms of the 11 plan, fund, or program, either directly or through insurance, 12 reimbursement, or otherwise. 13 (2) With respect to a group health plan, the term “employer” 14 includes a partnership with respect to a partner. 15 (3) With respect to a group health plan, the term 16 “participant” includes the following: 17 (a) With respect to a group health plan maintained by a 18 partnership, an individual who is a partner in the partnership. 19 (b) With respect to a group health plan maintained by 20 a self-employed individual under which one or more of the 21 self-employed individual’s employees are participants, the 22 self-employed individual, if that individual is, or may become, 23 eligible to receive benefits under the plan or the individual’s 24 dependents may be eligible to receive benefits under the plan. 25 9. “Health care services” means services, the coverage of 26 which is authorized under chapter 509, 514, 514A, or 514B and 27 includes services for the purposes of preventing, alleviating, 28 curing, or healing human illness, injury, or physical 29 disability. 30 10. “Health insurance” means accident and sickness insurance 31 authorized by chapter 509, 514, or 514A. 32 11. a. “Health insurance coverage” means health insurance 33 coverage offered to individuals, including group conversion 34 coverage. 35 -13- LSB 5392XS (19) 83 pf:av/rj 13/ 27

S.F. 2092 b. “Health insurance coverage” does not include any of the 1 following: 2 (1) Coverage for accident-only or disability income 3 insurance. 4 (2) Coverage issued as a supplement to liability insurance. 5 (3) Liability insurance, including general liability 6 insurance and automobile liability insurance. 7 (4) Workers’ compensation or similar insurance. 8 (5) Automobile medical-payment insurance. 9 (6) Credit-only insurance. 10 (7) Coverage for on-site medical clinic care. 11 (8) Other similar insurance coverage, specified in 12 federal regulations, under which benefits for medical care 13 are secondary or incidental to other insurance coverage or 14 benefits. 15 c. “Health insurance coverage” does not include benefits 16 provided under a separate policy as follows: 17 (1) Limited-scope dental or vision benefits. 18 (2) Benefits for long-term care, nursing home care, home 19 health care, or community-based care. 20 (3) Any other similar limited benefits as provided by rule 21 of the commissioner. 22 d. “Health insurance coverage” does not include benefits 23 offered as independent noncoordinated benefits as follows: 24 (1) Coverage only for a specified disease or illness. 25 (2) A hospital indemnity or other fixed indemnity 26 insurance. 27 e. “Health insurance coverage” does not include Medicare 28 supplemental health insurance as defined under section 29 1882(g)(1) of the federal Social Security Act, coverage 30 supplemental to the coverage provided under 10 U.S.C. ch. 55 31 and similar supplemental coverage provided to coverage under 32 group health insurance coverage. 33 12. “Medical assistance program” means the federal-state 34 assistance program established under Tit. XIX of the federal 35 -14- LSB 5392XS (19) 83 pf:av/rj 14/ 27

S.F. 2092 Social Security Act and chapter 249A. 1 13. “Medicare” means the federal government health insurance 2 program established under Tit. XVIII of the federal Social 3 Security Act. 4 14. “Organized delivery system” means an organized delivery 5 system as licensed by the director of public health. 6 Sec. 17. NEW SECTION . 514M.4 Iowa choice exchange 7 created —— board of directors. 8 1. An Iowa choice exchange is created as a nonprofit 9 corporation under the purview of the insurance division of the 10 department of commerce. 11 a. All carriers and all organized delivery systems licensed 12 by the director of public health providing health insurance or 13 health care services in Iowa, whether on an individual or group 14 basis, and all other insurers designated by the exchange’s 15 board of directors and approved by the commissioner shall be 16 members of the exchange. 17 b. The exchange shall operate under a plan of operation 18 established and approved under section 514M.5 and shall 19 exercise its powers through a board of directors established 20 under this section. 21 2. The board of directors of the exchange shall consist of 22 the following members: 23 a. The following persons who are voting members of the board 24 appointed by the governor and subject to confirmation by the 25 senate: 26 (1) A health care academic with a background in economics, 27 law, or public health. 28 (2) An executive of a carrier. 29 (3) A health benefits manager of a company. 30 (4) A health care analyst representing a public or private 31 employee bargaining unit. 32 (5) A health care analyst representing an organized 33 consumer group. 34 (6) A health care provider. 35 -15- LSB 5392XS (19) 83 pf:av/rj 15/ 27

S.F. 2092 (7) An insurance agent. 1 b. The following persons who are ex officio, nonvoting 2 members of the board: 3 (1) The commissioner of insurance, or a designee. 4 (2) The Iowa Medicaid director, or a designee. 5 (3) Four members of the general assembly, one appointed 6 by the speaker of the house of representatives, one appointed 7 by the minority leader of the house of representatives, 8 one appointed by the majority leader of the senate, and one 9 appointed by the minority leader of the senate. 10 c. Each member of the board appointed by the governor shall 11 be a resident of this state and the composition of voting 12 members of the board shall be in compliance with sections 13 69.16, 69.16A, and 69.16C. 14 d. The voting members of the board shall be appointed for 15 terms of six years beginning and ending as provided in section 16 69.19. A member of the board is eligible for reappointment. 17 The governor shall fill a vacancy for the remainder of the 18 unexpired term. A member of the board may be removed by the 19 governor for misfeasance, malfeasance, or willful neglect of 20 duty or other cause after notice and a public hearing unless 21 the notice and hearing are waived by the member in writing. 22 e. The voting members of the board shall annually elect one 23 of the members as chairperson and one as vice chairperson. 24 f. A majority of the voting members of the board constitutes 25 a quorum. The affirmative vote of a majority of the voting 26 members is necessary for any action taken by the board. 27 The majority shall not include a member who has a conflict 28 of interest and a statement by a member of a conflict of 29 interest is conclusive for this purpose. A vacancy in the 30 voting membership of the board does not impair the right of a 31 quorum to exercise the rights and perform the duties of the 32 board. An action taken by the board under this chapter may be 33 authorized by resolution at a regular or special meeting and 34 each resolution may take effect immediately and need not be 35 -16- LSB 5392XS (19) 83 pf:av/rj 16/ 27

S.F. 2092 published or posted. Meetings of the board shall be held at 1 the call of the chairperson or at the request of a majority of 2 the voting members. 3 g. Members of the board may be reimbursed from the moneys 4 of the exchange for expenses incurred by them as members, but 5 shall not be otherwise compensated by the exchange for their 6 services. 7 h. The voting members of the board shall give bond as 8 required for public officers in chapter 64. 9 i. The members of the board are subject to and are officials 10 within the meaning of chapter 68B. 11 j. All employees of the exchange are exempt from chapter 8A, 12 subchapter IV, and chapter 97B. 13 3. The voting members of the board shall appoint an 14 executive director to supervise the administrative affairs 15 and general management and operations of the exchange. The 16 executive director shall not be a member of the board, 17 shall serve at the pleasure of the board, and shall receive 18 compensation as fixed by the board. The executive director 19 shall keep a record of the proceedings of the board and shall 20 be custodian of all books, documents, and papers filed with 21 the board, the minute book or journal of the board, and the 22 official seal of the board. The executive director may cause 23 copies to be made of minutes and other records and documents of 24 the board and may give certificates under the official seal of 25 the board that the copies are true copies, and persons dealing 26 with the board may rely upon the certificates. 27 4. The exchange shall be considered a governmental body 28 for the purposes of chapter 21 and a government body for the 29 purposes of chapter 22. 30 5. The board may hire independent consultants, as they deem 31 necessary, to assist them in carrying out the provisions of 32 this chapter. 33 Sec. 18. NEW SECTION . 514M.5 Plan of operation —— 34 assessments. 35 -17- LSB 5392XS (19) 83 pf:av/rj 17/ 27

S.F. 2092 1. The board shall submit to the commissioner a plan 1 of operation for the exchange and any amendments necessary 2 or suitable to assure the fair, reasonable, and equitable 3 administration of the exchange within ninety days after the 4 appointment of the board. After notice and hearing, the 5 commissioner shall approve the plan of operation if the plan 6 is determined to be suitable to assure the fair, reasonable, 7 and equitable administration of the exchange, and includes a 8 methodology that may be used to share exchange costs on an 9 equitable and proportionate basis among the member carriers. 10 In addition to other requirements, the plan of operation shall 11 provide for all of the following: 12 a. The handling and accounting of assets and moneys of the 13 exchange. 14 b. The amount and method of reimbursing expenses of the 15 members of the board. 16 c. Regular times and places for meetings of the board. 17 d. Records to be kept of all financial transactions, and the 18 annual fiscal reporting to the commissioner. 19 e. The periodic advertising of the general availability of 20 health coverage information and assistance from the exchange. 21 f. Additional provisions necessary or proper for the 22 execution of the powers and duties of the exchange. 23 2. The exchange has the general powers and authority 24 enumerated by this section and pursuant to section 514M.6 and 25 executed in accordance with the plan of operation approved by 26 the commissioner under subsection 1. 27 3. Following the close of each calendar year, the exchange 28 shall determine the net payments received, the expenses of 29 administration, and the incurred costs of the exchange for 30 the year. The exchange shall certify the amount of any net 31 costs for the preceding calendar year to the commissioner 32 and director of revenue. The net costs may be assessed by 33 the exchange to all members of the exchange in proportion to 34 their respective shares of total health insurance premiums 35 -18- LSB 5392XS (19) 83 pf:av/rj 18/ 27

S.F. 2092 or payments for subscriber contracts received in Iowa during 1 the second preceding calendar year, coinciding with or ending 2 during the calendar year or on any other equitable basis as 3 provided in the plan of operation. In sharing costs, the 4 exchange may abate or defer in any part the assessment of 5 a member, if, in the opinion of the board, payment of the 6 assessment would endanger the ability of the member to fulfill 7 its contractual obligations. The exchange may also provide 8 for an initial or interim assessment against members of the 9 exchange if necessary to assure the financial capability of the 10 exchange to meet the incurred or estimated operating costs of 11 the exchange until the next calendar year is completed. Net 12 gains of the exchange, if any, shall be held by the exchange at 13 interest to offset future costs. 14 a. For purposes of this subsection, “total health insurance 15 premiums” and “payments for subscriber contracts” include, 16 without limitation, premiums or other amounts paid to or 17 received by a member for individual and group health plan 18 coverage provided under any chapter of the Code or Iowa Acts, 19 and “paid losses” includes, without limitation, claims paid by 20 a member operating on a self-funded basis for individual and 21 group health plan coverage provided under any chapter of the 22 Code or Iowa Acts. 23 b. For purposes of calculating and conducting the assessment 24 under this subsection, the exchange shall have the express 25 authority to require members to report on an annual basis each 26 member’s total health insurance premiums and payments for 27 subscriber contracts and paid losses. 28 4. The exchange shall conduct annual audits to assure 29 the general accuracy of the financial data submitted to the 30 exchange, and the exchange shall have an annual audit of its 31 operations, made by an independent certified public accountant. 32 5. The exchange is subject to examination by the 33 commissioner. Not later than April 30 of each year, the board 34 shall submit to the commissioner a financial report for the 35 -19- LSB 5392XS (19) 83 pf:av/rj 19/ 27

S.F. 2092 preceding calendar year in a form approved by the commissioner. 1 6. The exchange is subject to oversight by the legislative 2 fiscal committee of the legislative council. Not later than 3 April 30 of each year, the board shall submit to the governor, 4 the speaker of the house of representatives, the majority 5 leader of the senate, and the legislative fiscal committee a 6 financial report for the preceding year in a form approved by 7 the legislative fiscal committee. 8 7. The exchange is exempt from payment of all fees and 9 all taxes levied by this state or any of its political 10 subdivisions. 11 8. The exchange shall develop and implement a plan of 12 operation and corresponding timeline detailing action steps 13 toward implementing this chapter, by rules adopted pursuant to 14 chapter 17A as provided in section 514M.7. 15 Sec. 19. NEW SECTION . 514M.6 Powers and duties of exchange. 16 1. The exchange shall develop a system that provides 17 a portal where uninsured Iowans can receive assistance in 18 obtaining public or private health care coverage. In doing 19 so the exchange shall contract with the department of human 20 services to determine the eligibility of uninsured Iowans for 21 public programs and to provide assistance with enrollment in 22 the appropriate public programs. The exchange shall provide 23 assistance with obtaining private health insurance coverage 24 that meets certain standards of quality and affordability 25 to uninsured Iowans who are not eligible for or do not wish 26 to enroll in public programs. The exchange shall develop 27 a seamless system that allows individuals to move between 28 public and private health care coverage, including increasing 29 opportunities for obtaining creditable coverage. 30 2. The exchange shall establish quality standards for 31 private health insurance coverage that has three levels 32 of benefits including basic or catastrophic benefits, an 33 intermediate level of benefits, and comprehensive benefits 34 coverage, and that meets affordability limits established 35 -20- LSB 5392XS (19) 83 pf:av/rj 20/ 27