House File 83 - Introduced HOUSE FILE 83 BY HEDDENS , WESSEL-KROESCHELL , ISENHART , MURPHY , BERRY , GASKILL , HUNTER , WOOD , COHOON , DAWSON , M. SMITH , BEARINGER , KRESSIG , T. TAYLOR , STAED , MASCHER , OURTH , WINCKLER , STUTSMAN , THEDE , H. MILLER , ANDERSON , STECKMAN , HANSON , LENSING , OLDSON , and THOMAS A BILL FOR An Act relating to integrated care models for the delivery 1 of health care, including but not limited to required 2 utilization of a medical home by individuals currently and 3 newly eligible for coverage under the Medicaid program and 4 including effective date provisions. 5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 6 TLSB 1441YH (2) 85 pf/rj

H.F. 83 Section 1. Section 135.157, subsections 4 and 6, Code 2013, 1 are amended to read as follows: 2 4. “Medical home” means a team approach to providing health 3 care that originates in a primary care setting; fosters a 4 partnership among the patient, the personal provider, and 5 other health care professionals, and where appropriate, the 6 patient’s family; utilizes the partnership to access and 7 integrate all medical and nonmedical health-related services 8 across all elements of the health care system and the patient’s 9 community as needed by the patient and the patient’s family 10 to achieve maximum health potential; maintains a centralized, 11 comprehensive record of all health-related services to 12 promote continuity of care; and has all of the characteristics 13 specified in section 135.158 . 14 6. “Personal provider” means the patient’s first point of 15 contact in the health care system with a primary care provider 16 who identifies the patient’s health health-related needs and, 17 working with a team of health care professionals and providers 18 of medical and nonmedical health-related services , provides 19 for and coordinates appropriate care to address the health 20 health-related needs identified. 21 Sec. 2. Section 135.158, subsection 2, paragraphs b, c, and 22 d, Code 2013, are amended to read as follows: 23 b. A provider-directed team-based medical practice. The 24 personal provider leads a team of individuals at the practice 25 level who collectively take responsibility for the ongoing 26 health care health-related needs of patients. 27 c. Whole person orientation. The personal provider is 28 responsible for providing for all of a patient’s health care 29 health-related needs or taking responsibility for appropriately 30 arranging health care for health-related services provided 31 by other qualified health care professionals and providers 32 of medical and nonmedical health-related services . This 33 responsibility includes health health-related care at all 34 stages of life including provision of preventive care, 35 -1- LSB 1441YH (2) 85 pf/rj 1/ 10

H.F. 83 acute care, chronic care, preventive services long-term 1 care, transitional care between providers and settings , and 2 end-of-life care. This responsibility includes whole-person 3 care consisting of physical health care including but not 4 limited to oral, vision, and other specialty care, pharmacy 5 management, and behavioral health care. 6 d. Coordination and integration of care. Care is 7 coordinated and integrated across all elements of the 8 complex health care system and the patient’s community. Care 9 coordination and integration provides linkages to community 10 and social supports to address social determinants of health, 11 to engage and support patients in managing their own health, 12 and to track the progress of these community and social 13 supports in providing whole-person care. Care is facilitated 14 by registries, information technology, health information 15 exchanges, and other means to assure that patients receive the 16 indicated care when and where they need and want the care in a 17 culturally and linguistically appropriate manner. 18 Sec. 3. Section 135.159, subsections 1, 9, and 11, Code 19 2013, are amended to read as follows: 20 1. The department shall administer the medical home system. 21 The department shall collaborate with the department of human 22 services in administering medical homes under the medical 23 assistance program. The department shall adopt rules pursuant 24 to chapter 17A necessary to administer the medical home system , 25 and shall collaborate with the department of human services in 26 adopting rules for medical homes under the medical assistance 27 program . 28 9. The department shall coordinate the requirements and 29 activities of the medical home system with the requirements 30 and activities of the dental home for children as described 31 in section 249J.14 , and shall recommend financial incentives 32 for dentists and nondental providers to promote oral health 33 care coordination through preventive dental intervention, early 34 identification of oral disease risk, health care coordination 35 -2- LSB 1441YH (2) 85 pf/rj 2/ 10

H.F. 83 and data tracking, treatment, chronic care management, 1 education and training, parental guidance, and oral health 2 promotions for children. Additionally, the department shall 3 establish requirements for the medical home system to provide 4 linkages to accessible dental homes for adults and older 5 individuals. 6 11. Implementation phases . 7 a. Initial implementation shall No later than July 1, 2014, 8 the department shall collaborate with the department of human 9 services to require participation in the medical home system of 10 children all of the following: 11 (1) Children who are recipients of full benefits under the 12 medical assistance program. The department shall work with 13 the department of human services and shall recommend to the 14 general assembly a reimbursement methodology to compensate 15 providers participating under the medical assistance program 16 for participation in the medical home system. 17 b. (2) The department shall work with the department of 18 human services to expand the medical home system to adults 19 Adults who are recipients of full benefits under the medical 20 assistance program and the expansion population under the 21 IowaCare program including those adults who are recipients of 22 benefits under section 249A.3, subsection 1, paragraph “v” , in 23 accordance with the federal Patient Protection and Affordable 24 Care Act, Pub. L. No. 111-148, § 2001, as amended by the 25 federal Health Care and Education Reconciliation Act of 2010, 26 Pub. L. No. 111-152 . 27 (3) The department shall work with Medicare and dually 28 eligible Medicare and Medicaid recipients, to the extent 29 approved by the centers for Medicare and Medicaid services of 30 the United States department of health and human services to 31 allow Medicare recipients to utilize the medical home system . 32 c. b. The department shall work with the department of 33 administrative services to allow state employees to utilize the 34 medical home system. 35 -3- LSB 1441YH (2) 85 pf/rj 3/ 10

H.F. 83 d. c. The department shall work with insurers and 1 self-insured companies, if requested, to make the medical 2 home system available to individuals with private health care 3 coverage. 4 Sec. 4. Section 249A.3, subsection 1, Code 2013, is amended 5 by adding the following new paragraph: 6 NEW PARAGRAPH . v. Beginning January 1, 2014, is an 7 individual who is nineteen years of age or older and under 8 age sixty-five; is not pregnant; is not entitled to or 9 enrolled for Medicare benefits under part A, or enrolled 10 for Medicare benefits under part B, of Tit. XVIII of the 11 federal Social Security Act; is not otherwise described in 12 section 1902a(a)(10)(A)(i) of the federal Social Security 13 Act; and whose income is at or below one hundred thirty-three 14 percent of the federal poverty level as defined by the most 15 recently revised poverty income guidelines published by the 16 United States department of health and human services for the 17 applicable family size and as calculated in accordance with 18 the federal Patient Protection and Affordable Care Act, Pub. 19 L. No. 111-148, § 2001, as amended by the federal Health Care 20 and Education Reconciliation Act of 2010, Pub. L. No. 111-152. 21 Individuals eligible for medical assistance under this 22 paragraph shall receive benefits which are at a minimum those 23 included in the medical assistance state plan benefit package 24 offered in the state, to be adjusted as necessary to provide 25 essential health benefits as required pursuant to section 1302 26 of the federal Patient Protection and Affordable Care Act, Pub. 27 L. No. 111-148, and as approved by the United States secretary 28 of health and human services. 29 Sec. 5. Section 249J.26, subsection 2, Code 2013, is amended 30 to read as follows: 31 2. This chapter is repealed October December 31, 2013. The 32 department shall prepare a plan for the transition of expansion 33 population members to other health care coverage options. 34 The options shall include the option of coverage through the 35 -4- LSB 1441YH (2) 85 pf/rj 4/ 10

H.F. 83 medical assistance program as provided in section 249A.3, 1 subsection 1, paragraph “v” , relating to coverage for adults who 2 are nineteen years of age or older and under age sixty-five, 3 and the option of coverage through the health benefits exchange 4 established pursuant to the federal Patient Protection and 5 Affordable Care Act, Pub. L. No. 111-148, as amended by the 6 federal Health Care and Education Reconciliation Act of 2010, 7 Pub. L. No. 111-152. To the greatest extent possible, the plan 8 shall maintain and incorporate utilization of the existing 9 medical home and service delivery structure as developed 10 under this chapter, including the utilization of federally 11 qualified health centers, public hospitals, and other safety 12 net providers, in providing access to care. The department 13 shall submit the plan to the governor and the general assembly 14 no later than September 1, 2013. 15 Sec. 6. LEGISLATIVE COMMISSION ON INTEGRATED CARE MODELS. 16 1. No later than thirty days after the effective date 17 of this Act, the legislative council shall establish a 18 legislative commission to review and make recommendations 19 relating to the formation and operation of integrated care 20 models (ICMs) in the state. The models include any care 21 delivery model that integrates providers and incorporates a 22 financial incentive to improve patient health outcomes, improve 23 care, and reduce costs. Integrated care models include but 24 are not limited to patient-centered medical homes or health 25 homes, accountable care organizations (ACOs), ACO-like models, 26 community and regional care networks, and other integrated and 27 accountable delivery models that utilize value-based financing 28 methodologies and emphasize person-centered, coordinated, and 29 comprehensive care. 30 2. a. In developing the recommendations, the legislative 31 commission shall review models created in other states that 32 integrate both clinical services and nonclinical community 33 and social supports utilizing patient-centered medical homes 34 and community care teams as basic components. These models 35 -5- LSB 1441YH (2) 85 pf/rj 5/ 10

H.F. 83 may include but are not limited to the ACO demonstration 1 program based on the Camden Coalition of Healthcare Providers 2 in Camden, New Jersey; the Medical Home Network in Chicago, 3 Illinois; the Health Commons model in New Mexico; the 4 Accountable Care Collaborative in Colorado; Community Care of 5 North Carolina, in North Carolina; the Blueprint for Health and 6 the Community Health Teams in Vermont; and the Coordinated Care 7 Organizations in Oregon. 8 b. The legislative commission shall specifically focus 9 on recommending the best means of providing care through 10 integrated delivery models throughout the state including to 11 vulnerable populations and how best to incorporate safety net 12 providers, including but not limited to federally qualified 13 health centers, rural health clinics, community mental health 14 centers, public hospitals, and other nonprofit and public 15 providers that have long experience in caring for vulnerable 16 populations, into the integrated system. 17 c. The legislative commission shall review opportunities 18 under the federal Patient Protection and Affordable Care Act 19 (Affordable Care Act), Pub. L. No. 11-148, as amended, for 20 the development of ICMs including the Medicare Shared Savings 21 program for accountable care organizations, community-based 22 collaborative care networks that include safety net providers, 23 consumer-operated and oriented plans, and opportunities 24 through the Center for Medicare and Medicaid Innovation 25 (CMI) established pursuant to section 3021 of the Affordable 26 Care Act. The legislative commission shall also review 27 existing and proposed integrated care models in the state 28 including commercial models and those developed or proposed 29 under the Accountable Care Act including the Medicare Shared 30 Savings Program, the Pioneer ACO, and the application for 31 the multipayer Medicaid ACO developed through the CMI State 32 Innovation Models Initiative. 33 d. The legislative commission shall address the issues 34 relative to ICMs including those relating to consumer 35 -6- LSB 1441YH (2) 85 pf/rj 6/ 10

H.F. 83 protection including those that relate to confidentiality, 1 quality assurance, grievance procedures, and appeals of patient 2 care decisions; payment methodologies, multipayer alignment, 3 coordination of funding streams, and financing methods that 4 support full integration of clinical and nonclinical services 5 and providers; organizational, management, and governing 6 structures; access, quality, outcomes, utilization, and 7 other appropriate performance standards; patient attribution 8 or assignment models; health information exchange, data, 9 reporting, and infrastructure standards; and regulatory 10 issues including clinical integration limitations, physician 11 self-referral, antikickback provisions, gain-sharing, 12 beneficiary inducements, antitrust issues, tax exemption 13 issues, and application of insurance regulations. 14 3. The legislative commission shall consult with advocates 15 representing patients, health care providers, health care 16 payers, and other appropriate parties in developing the 17 recommendations relating to ICMs. 18 4. The legislative commission may request from any state 19 agency or official information and assistance as needed to 20 perform the review and make recommendations. 21 5. The legislative commission shall submit a final report 22 summarizing the legislative commission’s activities, analyzing 23 the issues reviewed, and making recommendations to the governor 24 and the general assembly by September 1, 2013. 25 Sec. 7. MEDICAID STATE PLAN. 26 1. The department of human services shall amend the medical 27 assistance state plan to reflect the required provision of a 28 medical home to medical assistance recipients as provided in 29 this Act. 30 2. The department of human services shall amend the medical 31 assistance state plan to provide for coverage of adults up to 32 133 percent of the federal poverty level as provided in this 33 Act and in accordance with the federal Patient Protection and 34 Affordable Care Act, Pub. L. No. 111-148, § 2001, as amended 35 -7- LSB 1441YH (2) 85 pf/rj 7/ 10

H.F. 83 by the federal Health Care and Education Reconciliation Act of 1 2010, Pub. L. No. 111-152. 2 3. The department of human services shall amend the medical 3 assistance state plan to provide that the benchmark benefit 4 plan provided to the newly covered adults under the medical 5 assistance program is the option of secretary-approved coverage 6 which is at a minimum the Medicaid state plan benefit package 7 offered in the state, to be adjusted as necessary to provide 8 essential health benefits as required pursuant to section 9 1302(b) of the Patient Protection and Affordable Care Act, Pub. 10 L. No. 111-148. 11 Sec. 8. EFFECTIVE UPON ENACTMENT. This Act, being deemed of 12 immediate importance, takes effect upon enactment. 13 EXPLANATION 14 This bill relates to integrated health care delivery models. 15 The bill amends provisions relating to medical homes to 16 require a team-based, multidisciplinary approach to health 17 care delivery. The bill requires the department of human 18 services (DHS) to collaborate with the department of public 19 health (DPH) in administering medical homes under the Medicaid 20 program. The bill amends provisions relating to implementation 21 of medical homes in the state by requiring all children and 22 adults who are recipients of full benefits under the medical 23 assistance program, including adults up to 133 percent of 24 the federal poverty level who are eligible under the federal 25 Patient Protection and Affordable Care Act (ACA), Pub. L. No. 26 111-148, § 2001, as amended by the federal Health Care and 27 Education Reconciliation Act of 2010, Pub. L. No. 111-152, and 28 individuals who are dually eligible to the extent approved by 29 the centers for Medicare and Medicaid services of the United 30 States department of health and human services (CMS), to 31 participate in a medical home not later than July 1, 2014. 32 The bill does not amend the Code provisions directing DPH to 33 work with the department of administrative services to allow 34 state employees to utilize the medical home system and to work 35 -8- LSB 1441YH (2) 85 pf/rj 8/ 10

H.F. 83 with insurers and self-insured companies, if requested, to make 1 the medical home system available to individuals with private 2 health care coverage. 3 The bill provides for Medicaid eligibility of certain adults 4 with incomes at or below 133 percent of the federal poverty 5 level in accordance with the ACA. Additionally, the bill 6 requires that these newly eligible adults receive benefits 7 which are included in the medical assistance state plan 8 benefit package offered in the state as adjusted to provide 9 the essential health benefits required under the ACA, and as 10 approved by the United States secretary of health and human 11 services. 12 The bill directs the legislative council to establish a 13 legislative commission to review and make recommendations 14 for the formation and operation of integrated care models 15 (ICM) in the state. The bill describes ICMs as any care 16 delivery model that integrates providers and incorporates 17 a financial incentive to improve patient health outcomes, 18 improve care, and reduce costs. ICMs include but are not 19 limited to patient-centered medical homes or health homes, 20 accountable care organizations (ACOs), ACO-like models, and 21 other integrated and accountable health delivery models that 22 utilize value-based financing methodologies and emphasize 23 person-centered, coordinated, comprehensive care. The 24 legislative commission is directed to consult with advocates 25 representing patients, health care providers, health care 26 payers, and other appropriate parties in developing the 27 recommendations for ICMs; to specifically address certain 28 issues to review existing ICMs in other states as well as 29 those existing or proposed in the state Medicare Shared 30 Savings Program, the Pioneer ACO, and the Center for 31 Medicare and Medicaid Innovation State Innovation Models 32 Initiative application to implement a multipayer ACO including 33 Medicaid. The legislative commission is required to make its 34 recommendations to the governor and the general assembly by 35 -9- LSB 1441YH (2) 85 pf/rj 9/ 10