House Study Bill 232 - Introduced HOUSE FILE _____ BY (PROPOSED COMMITTEE ON APPROPRIATIONS BILL BY CHAIRPERSON SODERBERG) A BILL FOR An Act relating to establishing a healthy Iowa plan, and making 1 appropriations. 2 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 3 TLSB 2517YC (11) 85 pf/rj

H.F. _____ Section 1. NEW SECTION . 249N.1 Title. 1 This chapter shall be known and may be cited as the “Healthy 2 Iowa Plan” . 3 Sec. 2. NEW SECTION . 249N.2 Definitions. 4 As used in this chapter, unless the context otherwise 5 requires: 6 1. “Accountable care organization” means a risk-bearing, 7 integrated health care organization characterized by a payment 8 and care delivery model that ties provider reimbursement to 9 quality metrics and reductions in the total cost of care for an 10 assigned population of patients. 11 2. “Accountable care provider network” means the health care 12 delivery network approved by the department for healthy Iowa 13 plan members. 14 3. “Affordable Care Act” or “federal Act” means the federal 15 Patient Protection and Affordable Care Act, Pub. L. No. 16 111-148. 17 4. “Benchmark coverage” means health benefits coverage that 18 is equal to the coverage under one or more of the benefit plans 19 specified in 42 U.S.C. § 1396u-7(b)(1) and 42 C.F.R. § 440.330. 20 5. “Clean claim” means a claim submitted by a provider 21 included in the accountable care provider network that may be 22 adjudicated as paid or denied. 23 6. “Covered benefits” means reimbursable health care 24 services as specified in section 249N.6. 25 7. “Department” means the department of human services. 26 8. “Director” means the director of human services. 27 9. “Essential health benefits” means essential health 28 benefits as defined in section 1302 of the Affordable Care Act, 29 that include at least the general categories and the items and 30 services covered within the categories of ambulatory patient 31 services; emergency services; hospitalization; maternity 32 and newborn care; mental health and substance use disorder 33 services, including behavioral health treatment; prescription 34 drugs; rehabilitative and habilitative services and devices; 35 -1- LSB 2517YC (11) 85 pf/rj 1/ 21

H.F. _____ laboratory services; preventive and wellness services and 1 chronic disease management; and pediatric services, including 2 oral and vision care. 3 10. “Federal approval” means approval by the centers for 4 Medicare and Medicaid services of the United States department 5 of health and human services. 6 11. “Federal poverty level” means the most recently revised 7 poverty income guidelines published by the United States 8 department of health and human services. 9 12. “Full benefits recipient” means an adult who is eligible 10 for full medical assistance benefits pursuant to chapter 249A 11 under any category of eligibility. 12 13. “Healthy Iowa plan” means the healthy Iowa plan 13 established under this chapter. 14 14. “Healthy Iowa plan provider” means any provider enrolled 15 in the medical assistance program under the accountable care 16 provider network. 17 15. “Iowa plan” means the managed care plan under contract 18 with the department to manage mental health and substance use 19 disorder services under the medical assistance program. 20 16. “Medical assistance program” or “Medicaid” means the 21 program paying all or part of the costs of care and services 22 provided to an individual pursuant to chapter 249A and Tit. XIX 23 of the federal Social Security Act. 24 17. “Medicare” means the federal Medicare program 25 established pursuant to Tit. XVIII of the federal Social 26 Security Act. 27 18. “Member” means an individual who meets the eligibility 28 requirements of section 249N.5 and is enrolled in the healthy 29 Iowa plan. 30 19. “My health rewards account” means an account established 31 by the department pursuant to section 249N.9 on behalf of a 32 member to contain contributions from the member and financial 33 incentives and other payments by the plan to be used for 34 payment of required contributions, cost-sharing, and health 35 -2- LSB 2517YC (11) 85 pf/rj 2/ 21

H.F. _____ improvements by the member. 1 20. “Preventive care services” means care that is provided 2 to an individual to promote health, prevent disease, or 3 diagnose disease. 4 21. “Primary medical provider” means the primary care 5 provider chosen by a member or to whom a member is assigned to 6 provide and manage the member’s primary care and to provide 7 referrals, as necessary and required by the plan, to other 8 providers within the accountable care provider network. 9 22. “Public hospital” means a hospital licensed pursuant to 10 chapter 135B and governed pursuant to chapter 145A, 226, 347, 11 347A, or 392. 12 23. “Secretary” means the United States secretary of health 13 and human services. 14 24. “Value-based reimbursement” means a payment methodology 15 that links provider reimbursement to improved performance 16 by health care providers by holding health care providers 17 accountable for both the cost and quality of care provided. 18 Sec. 3. NEW SECTION . 249N.3 Purpose —— establishment of 19 healthy Iowa plan. 20 1. The purpose of this chapter is to establish and 21 administer a healthy Iowa plan to promote increased access 22 to health care, quality health care outcomes, and the use of 23 personal responsibility mechanisms that encourage individuals 24 with incomes below one hundred percent of the federal poverty 25 level to be cost-conscious consumers of health care and to 26 exhibit healthy behaviors. 27 2. The healthy Iowa plan is established within the medical 28 assistance program and shall be administered by the department. 29 Except as otherwise specified in this chapter, the rules 30 applicable to the medical assistance program pursuant to 31 chapter 249A shall be applicable to the healthy Iowa plan. 32 Sec. 4. NEW SECTION . 249N.4 Federal financial participation 33 —— limitations of program. 34 1. This chapter shall be implemented only to the extent 35 -3- LSB 2517YC (11) 85 pf/rj 3/ 21

H.F. _____ that federal matching funds are available for nonfederal 1 expenditures under this chapter. The department shall not 2 expend funds under this chapter, including but not limited 3 to expenditures for reimbursement of providers and program 4 administration, if appropriated nonfederal funds are not 5 matched by federal financial participation. 6 2. Enrollment in the healthy Iowa plan may be limited, 7 closed, or reduced and the scope and duration of services 8 provided under the healthy Iowa plan may be limited, reduced, 9 or terminated if the department determines that federal 10 financial participation or appropriated nonfederal funds will 11 not be available to pay for existing or additional enrollment 12 costs. 13 3. The provisions of this chapter shall not be construed, 14 are not intended as, and shall not imply a grant of entitlement 15 to services for individuals who are eligible for healthy Iowa 16 plan benefits under this chapter or for utilization of services 17 that do not exist or are not otherwise available under this 18 chapter. Any state obligation to provide healthy Iowa plan 19 benefits pursuant to this chapter is limited to the extent of 20 the funds appropriated or distributed for the purposes of this 21 chapter. 22 4. The provisions of this chapter shall not be construed and 23 are not intended to affect the provision of services to medical 24 assistance program recipients existing on January 1, 2014. 25 Sec. 5. NEW SECTION . 249N.5 Healthy Iowa plan —— 26 eligibility. 27 1. Except as otherwise provided in this chapter, an 28 individual nineteen through sixty-four years of age shall be 29 eligible for the healthy Iowa plan benefits described in this 30 chapter when provided through the accountable care provider 31 network as described in this chapter, if the individual meets 32 all of the following conditions: 33 a. The individual is a United States citizen, is a resident 34 of Iowa, and provides a social security number upon application 35 -4- LSB 2517YC (11) 85 pf/rj 4/ 21

H.F. _____ for the plan. 1 b. The individual has household income at or below one 2 hundred percent of the federal poverty level. Household income 3 shall be determined using the modified adjusted gross income 4 methodology pursuant to section 2002 of the Affordable Care 5 Act. 6 c. The individual fulfills all other conditions of 7 participation in the healthy Iowa plan, including member 8 financial participation pursuant to section 249N.9. 9 2. Individuals otherwise eligible solely for family 10 planning benefits authorized under the medical assistance 11 family planning services waiver effective January 1, 2014, 12 as specified in 2004 Iowa Acts, chapter 1175, section 116, 13 subsection 8, may also be eligible for healthy Iowa plan 14 benefits under this chapter provided through the accountable 15 care provider network. 16 3. The following individuals are not eligible for the 17 healthy Iowa plan: 18 a. An individual eligible as a full benefits recipient under 19 the medical assistance program. 20 b. An individual who is a recipient of Medicare. 21 c. An individual who is pregnant and otherwise eligible for 22 the medical assistance program pursuant to section 249A.3. 23 d. An individual who is eligible for benefits through the 24 United States department of veterans affairs. 25 4. Each applicant for healthy Iowa plan benefits shall 26 provide to the department all insurance information required 27 by the health insurance premium payment program in accordance 28 with rules adopted by the department. The department may 29 elect to pay the cost of premiums for applicants with access 30 to employer-sponsored health care coverage if the department 31 determines such payment to be cost-effective. 32 5. The department shall implement the healthy Iowa plan in 33 a manner that ensures that the healthy Iowa plan is the payor 34 of last resort. 35 -5- LSB 2517YC (11) 85 pf/rj 5/ 21

H.F. _____ 6. Following initial enrollment, a member is eligible 1 for healthy Iowa plan benefits for twelve months, subject to 2 program termination and other limitations otherwise specified 3 in this chapter. The department shall review the member’s 4 eligibility on at least an annual basis. 5 7. Upon enrollment, a member shall choose a primary medical 6 provider within the accountable care provider network. If 7 the member does not choose a primary medical provider, the 8 department shall assign the member to a primary medical 9 provider in accordance with the mandatory enrollment provisions 10 specified in rules adopted by the department pursuant to 11 chapter 249A and in accordance with quality data available to 12 the department. To the extent possible, a member shall have a 13 choice of primary medical provider, subject to the limitations 14 and the results of attribution specified in section 249N.7. 15 8. The department may contract with a third-party 16 administrator to administer eligibility determination, 17 enrollment, member outreach, my health rewards account 18 services, and other components of the healthy Iowa plan. 19 Sec. 6. NEW SECTION . 249N.6 Healthy Iowa plan —— covered 20 benefits. 21 1. Covered benefits under the healthy Iowa plan shall 22 include benefits that meet the requirements of alternative 23 benefit plans under section 1937 of the federal Social Security 24 Act as modified by section 1302 of the Affordable Care Act, and 25 shall, at a minimum, include essential health benefits. 26 2. Benefits under the healthy Iowa plan shall include but 27 are not limited to all of the following: 28 a. Preventive care services. 29 b. Health home services. 30 c. Physician services. 31 d. Inpatient and outpatient hospital services. 32 e. Emergency transportation services. 33 f. Prescription drugs. 34 g. Diagnostic services. 35 -6- LSB 2517YC (11) 85 pf/rj 6/ 21

H.F. _____ h. Durable medical equipment and medical supplies. 1 i. Rehabilitative services, including therapy services. 2 j. Home health services. 3 k. Mental health and substance use disorder services 4 administered through the Iowa plan. 5 l. Podiatry services. 6 Sec. 7. NEW SECTION . 249N.7 Healthy Iowa plan accountable 7 care provider network. 8 1. The healthy Iowa plan accountable care provider network 9 shall include all providers enrolled in the medical assistance 10 program as a healthy Iowa plan provider. Reimbursement under 11 this chapter shall only be made to such healthy Iowa plan 12 providers for benefits specified in section 249N.6. 13 2. The department shall develop a statewide accountable 14 care provider network by partitioning the state into regions. 15 3. The accountable care provider network shall include at 16 least one accountable care organization per region with which 17 the department shall contract to ensure the coordination and 18 management of the health of the members within the region, to 19 produce improved health care quality, and to control overall 20 cost. The department shall contract with the acute care 21 teaching hospital located in a county with a population over 22 three hundred fifty thousand to act as an accountable care 23 organization within the region specified by the department. 24 a. The department shall establish the qualifications, 25 contracting processes, and contract terms for an accountable 26 care organization. The department shall also establish a 27 methodology for attribution of a specified member population to 28 the accountable care organization. 29 b. An accountable care organization contract shall establish 30 accountability based on quality performance and total cost of 31 care metrics for the attributed population. The metrics shall 32 include but are not limited to risk sharing, including both 33 shared savings and shared costs, between the state and the 34 organization. 35 -7- LSB 2517YC (11) 85 pf/rj 7/ 21

H.F. _____ c. The department shall ensure that payments made to 1 accountable care organizations do not exceed available funds in 2 the healthy Iowa account created in section 249N.11. 3 d. In order to participate in the accountable care provider 4 network, a primary medical provider shall contract with the 5 accountable care organization responsible in the region to 6 provide for member coordination of care. The accountable care 7 organization shall provide access by members to primary medical 8 providers within thirty miles or thirty minutes of a member’s 9 residence, unless such access is technically infeasible. 10 4. To the extent possible, members shall have a choice of 11 providers within the accountable care provider network, subject 12 to the results of attribution under this section and subject 13 to all of the following: 14 a. Member choice may be limited by the accountable care 15 organization, with prior approval of the department, if the 16 member’s health condition would benefit from limiting the 17 member’s choice of a healthy Iowa plan provider to ensure 18 coordination of services, or due to overutilization of covered 19 benefits. The accountable care organization shall provide 20 thirty days’ notice to the member prior to limitation of such 21 choice. 22 b. The department may require that access to services not 23 provided through the accountable care organization be subject 24 to prior authorization by the accountable care organization, if 25 such prior authorization is projected to improve health care 26 delivery in the region. 27 5. a. A healthy Iowa plan provider shall be reimbursed for 28 covered benefits under the healthy Iowa plan utilizing the same 29 reimbursement methodology as that used for individuals eligible 30 for medical assistance under section 249A.3, subsection 1. 31 b. A healthy Iowa plan provider included in the accountable 32 care provider network shall submit clean claims within twenty 33 days of the date of provision of a covered service to a member. 34 c. Notwithstanding paragraph “a” , an accountable care 35 -8- LSB 2517YC (11) 85 pf/rj 8/ 21

H.F. _____ organization that is part of the accountable care provider 1 network under contract with the department shall be reimbursed 2 utilizing a value-based reimbursement methodology. 3 6. a. The department shall provide by rule for the exchange 4 of member health information among the member’s healthy Iowa 5 plan providers to facilitate coordination and management of 6 care, improved health outcomes, and reduction in costs. 7 b. The department shall provide a member’s health care 8 claims data to the member’s accountable care organization on a 9 timeframe established by rule. 10 Sec. 8. NEW SECTION . 249N.8 Member financial participation. 11 1. Membership in the healthy Iowa plan shall require 12 the payment of contributions and cost sharing based on 13 household income and ability to pay, not to exceed total 14 annual out-of-pocket expenditures of five percent of household 15 income. The department shall adopt rules pursuant to chapter 16 17A to establish the graduated schedule, including monthly 17 contributions, copayments, and deductibles. Copayments 18 shall not be applicable to preventive care or family planning 19 services. 20 2. a. Upon a determination of eligibility for the healthy 21 Iowa plan, a member shall not receive any benefits until the 22 initial monthly contribution payment is made, if applicable. 23 The plan is not liable for payment of the cost of any services 24 provided by a healthy Iowa plan provider to a member prior to 25 payment by the member of the initial monthly contribution. 26 b. Timely payment of monthly contributions, within 27 sixty days of the date the payment is due, is a condition of 28 membership. A member who does not make such timely payment is 29 subject to disenrollment from the plan, following notice from 30 the department. Following such disenrollment, an individual is 31 not eligible for reapplication for membership in the plan for 32 twelve months from the date of disenrollment. 33 c. A member may request a hardship exemption if a hardship 34 would accrue from imposing payment of the monthly contribution. 35 -9- LSB 2517YC (11) 85 pf/rj 9/ 21

H.F. _____ Information regarding the contribution obligation and 1 the hardship exemption, including the process by which a 2 prospective member may apply for the hardship exemption, shall 3 be provided to a prospective member at the time of application 4 for the plan. 5 d. The monthly contribution may be waived for a member 6 with a household income between zero and fifty percent of the 7 federal poverty level, upon completion of the health risk 8 assessment, annual physical, and preventive services specified 9 in section 249N.9. 10 3. Contributions collected under this section shall be 11 deposited in the member’s my health rewards account established 12 pursuant to section 249N.9. 13 Sec. 9. NEW SECTION . 249N.9 My health rewards accounts. 14 1. The department shall establish a my health rewards 15 account for each healthy Iowa plan member. 16 2. The moneys in a member’s account shall only be used 17 to improve the health of the member. The department shall 18 adopt rules pursuant to chapter 17A to specify a process for 19 distribution of moneys in a member’s account and use of moneys 20 in the account by the member based on best practices. Such 21 uses may include but are not limited to payment for smoking 22 cessation services or nutrition counseling, or payment of 23 required contributions or cost-sharing amounts, exclusive of 24 copayments for nonemergency use of an emergency department. 25 3. a. A member shall deposit all required contribution 26 amounts in the member’s my health rewards account. 27 b. The healthy Iowa plan shall deposit, annually, financial 28 incentives as established by rule pursuant to chapter 17A, in a 29 member’s my health rewards account, for the member’s completion 30 of a health risk assessment, completion of an annual physical, 31 and receipt of preventive services specified by the plan. The 32 plan shall also deposit, annually, a contribution amount that 33 is the difference between the sum of the required contributions 34 made by the member and the amounts deposited by the healthy 35 -10- LSB 2517YC (11) 85 pf/rj 10/ 21

H.F. _____ Iowa plan and the total annual deductible for the member as 1 established by rule. 2 4. If a member demonstrates an established pattern of 3 failure to pay required contribution or cost-sharing amounts, 4 or a pattern of inappropriate use of emergency department or 5 other benefits, the member may be subject to forfeiture of the 6 funds in the account, following notice from the department. 7 5. Any funds remaining in a member’s my health rewards 8 account annually at the end of a twelve-month enrollment period 9 are subject to the following: 10 a. If the member renews enrollment, the remaining funds 11 shall remain in the fund to be used to defray the cost of the 12 member’s contributions and cost-sharing requirements in the 13 subsequent enrollment period. However, if the member did not 14 complete the preventive services specified by the plan during 15 the prior enrollment period, the amount of any contributions 16 made by the plan shall not be used to defray the costs of the 17 member’s contributions or cost-sharing requirements in the 18 subsequent enrollment period. 19 b. If an individual is no longer eligible for the plan, does 20 not reenroll in the plan, or is terminated from the plan for 21 nonpayment of required contributions or cost sharing amounts, 22 the plan shall refund a prorated amount of the member’s 23 contributions, as determined by rule of the department, to the 24 individual within sixty days of such occurrence. 25 Sec. 10. NEW SECTION . 249N.10 Funding —— county and county 26 hospital contributions —— certified public expenditures. 27 1. Notwithstanding any provision to the contrary relating 28 to the taxes levied by a county pursuant to section 331.424A 29 for which the collection is performed after January 1, 30 2014, the county treasurer of each county shall distribute 31 thirty-seven and eighty-four hundredths percent of the maximum 32 amount authorized to be levied and collected pursuant to 33 section 331.424A, to the treasurer of state for deposit in the 34 healthy Iowa account created in section 249N.11. One-half 35 -11- LSB 2517YC (11) 85 pf/rj 11/ 21

H.F. _____ of the total amount specified under this subsection shall 1 be distributed by each county treasurer to the treasurer of 2 state by October 15, and one-half of the total amount shall be 3 distributed to the treasurer of state by April 15, annually. 4 2. Notwithstanding any provision to the contrary, for the 5 collection of taxes levied under section 347.7, for which the 6 collection is performed after January 1, 2014, the county 7 treasurer of a county with a population over three hundred 8 fifty thousand in which a publicly owned acute care teaching 9 hospital is located shall distribute the proceeds collected 10 pursuant to section 347.7, in a total amount of forty-two 11 million dollars annually, which would otherwise be distributed 12 to the county hospital, to the treasurer of state for deposit 13 in the healthy Iowa account created in section 249N.11 as 14 follows: 15 a. The first nineteen million dollars in collections 16 pursuant to section 347.7, between July 1 and December 31 17 annually, shall be distributed to the treasurer of state for 18 deposit in the healthy Iowa account and collections during 19 this time period in excess of nineteen million dollars shall 20 be distributed to the acute care teaching hospital identified 21 in this subsection. In addition, of the collections during 22 this time period in excess of nineteen million dollars received 23 by the acute care teaching hospital, two million dollars shall 24 be distributed by the acute care teaching hospital to the 25 treasurer of state for deposit in the healthy Iowa account in 26 the month of January following the July 1 through December 31 27 period. 28 b. The first nineteen million dollars in collections 29 pursuant to section 347.7, between January 1 and June 30 30 annually, shall be distributed to the treasurer of state for 31 deposit in the healthy Iowa account and collections during 32 this time period in excess of nineteen million dollars shall 33 be distributed to the acute care teaching hospital identified 34 in this subsection. In addition, of the collections during 35 -12- LSB 2517YC (11) 85 pf/rj 12/ 21

H.F. _____ this time period in excess of nineteen million dollars received 1 by the acute care teaching hospital, two million dollars shall 2 be distributed by the acute care teaching hospital to the 3 treasurer of state for deposit in the healthy Iowa account 4 in the month of July following the January 1 through June 30 5 period. 6 3. In addition to the funding specified in this section, the 7 university of Iowa hospitals and clinics shall certify public 8 expenditures in an amount equal to provide the nonfederal share 9 of total expenditures not to exceed thirty million dollars 10 annually. 11 Sec. 11. NEW SECTION . 249N.11 Healthy Iowa account. 12 1. A healthy Iowa account is created in the state treasury 13 under the authority of the department. Moneys appropriated 14 from the general fund of the state to the account, proceeds 15 distributed from county treasurers as specified in section 16 249N.10, and moneys from any other source credited to the 17 account shall be deposited in the account. Moneys deposited in 18 or credited to the account are appropriated to the department 19 of human services to be used for the purposes of the healthy 20 Iowa plan including administration of the plan and to provide 21 nonfederal matching funds for the healthy Iowa plan, as 22 specified in this chapter. 23 2. The account shall be separate from the general fund 24 of the state and shall not be considered part of the general 25 fund of the state. The moneys in the account shall not be 26 considered revenue of the state, but rather shall be funds of 27 the account. The moneys in the account are not subject to 28 section 8.33 and shall not be transferred, used, obligated, 29 appropriated, or otherwise encumbered, except to provide for 30 the purposes of this chapter. Notwithstanding section 12C.7, 31 subsection 2, interest or earnings on moneys deposited in the 32 account shall be credited to the account. 33 3. The department shall adopt rules pursuant to chapter 17A 34 to administer the account. 35 -13- LSB 2517YC (11) 85 pf/rj 13/ 21

H.F. _____ Sec. 12. NEW SECTION . 249N.12 Adoption of rules —— 1 sole-source administration. 2 1. The department shall adopt rules pursuant to chapter 17A 3 as necessary to administer this chapter. The department may 4 adopt emergency rules under section 17A.4, subsection 3, and 5 section 17A.5, subsection 2, paragraph “b” , as necessary for 6 the administration of this chapter and the rules shall become 7 effective immediately upon filing or on a later effective date 8 specified in the rules, unless the effective date is delayed by 9 the administrative rules review committee. Any rules adopted 10 in accordance with this section shall not take effect before 11 the rules are reviewed by the administrative rules review 12 committee. The delay authority provided to the administrative 13 rules review committee under section 17A.4, subsection 7, and 14 section 17A.8, subsection 9, shall be applicable to a delay 15 imposed under this section, notwithstanding a provision in 16 those sections making them inapplicable to section 17A.5, 17 subsection 2, paragraph “b” . Any rules adopted in accordance 18 with the provisions of this section shall also be published as 19 notice of intended action as provided in section 17A.4. 20 2. Notwithstanding section 8.47 or any other provision of 21 law to the contrary, the department may utilize a sole-source 22 approach to administer this chapter. 23 Sec. 13. Section 249J.26, subsection 2, Code 2013, is 24 amended to read as follows: 25 2. This chapter is repealed October December 31, 2013. 26 Sec. 14. DIRECTIVE TO DEPARTMENT OF HUMAN SERVICES. Upon 27 enactment of this Act, the department of human services shall 28 request federal approval of a medical assistance section 1115 29 demonstration waiver to implement this Act effective January 30 1, 2014. 31 Sec. 15. EFFECTIVE UPON ENACTMENT AND CONTINGENT 32 IMPLEMENTATION. 33 1. This Act, being deemed of immediate importance, takes 34 effect upon enactment. However, the department of human 35 -14- LSB 2517YC (11) 85 pf/rj 14/ 21

H.F. _____ services shall implement this Act effective January 1, 2014, 1 contingent and only upon receipt of federal approval of the 2 waiver request submitted under this Act. 3 2. Notwithstanding subsection 1, if any portion of 4 the waiver is denied or if federal approval or financial 5 participation relative to any portion of the waiver is denied, 6 the department shall only implement this Act in accordance with 7 both of the following: 8 a. To the extent that federal approval is received and 9 federal financial participation is available. 10 b. To the extent federal approval is not required and 11 federal participation is not applicable. 12 3. The distributions of taxes levied pursuant to section 13 331.424A and distributed by each county treasurer to the 14 treasurer of state pursuant to section 249N.10 and the 15 distribution of taxes levied pursuant to section 347.7 16 and distributed by the county treasurer of a county with 17 a population over three hundred fifty thousand in which a 18 publicly owned acute care teaching hospital is located to the 19 treasurer of state pursuant to section 249N.10, shall not be 20 distributed until the department of human services has received 21 federal approval of the waiver request submitted under this 22 Act. 23 Sec. 16. HEALTHY IOWA ACCOUNT —— APPROPRIATION FROM GENERAL 24 FUND. There is appropriated from the general fund of the state 25 for the fiscal year beginning July 1, 2013, and ending June 30, 26 2014, the following amount or so much thereof as is necessary 27 for the purposes designated: 28 For deposit in the healthy Iowa account to be used for the 29 purposes of the account: 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 23,000,000 31 EXPLANATION 32 This bill establishes a new Code chapter to be known and 33 cited as the “healthy Iowa plan”. 34 The bill provides definitions for the Code chapter. 35 -15- LSB 2517YC (11) 85 pf/rj 15/ 21

H.F. _____ The bill provides that the purpose of the healthy Iowa 1 plan is to promote increased access to health care, quality 2 health care outcomes, and the use of personal responsibility 3 mechanisms that encourage individuals with incomes below 100 4 percent of the federal poverty level (FPL) to be cost-conscious 5 consumers of health care and to exhibit healthy behaviors. The 6 healthy Iowa plan is established within the medical assistance 7 program and administered by the department of human services 8 (DHS). 9 The bill provides limitations to the healthy Iowa plan 10 including that implementation is limited to the extent 11 that federal matching funds are available for nonfederal 12 expenditures; and DHS is prohibited from expending funds if 13 appropriated nonfederal funds are not matched by federal 14 financial participation. Enrollment for the plan may be 15 limited, closed, or reduced and the scope and duration of 16 services provided may be limited, reduced, or terminated if 17 the department determines that federal financial participation 18 or appropriated nonfederal funds will not be available to pay 19 for existing or additional enrollment costs. The new Code 20 chapter is not to be construed as, is not intended as, and 21 does not imply a grant of entitlement for services to eligible 22 individuals or for utilization of services that do not exist 23 or are not otherwise available under the Code chapter. Any 24 state obligation to provide services under the Code chapter is 25 limited to the extent of the funds appropriated or distributed 26 for the purposes of the Code chapter. The Code chapter is not 27 to be construed to affect the provision of services to medical 28 assistance program recipients existing on January 1, 2014. 29 The bill provides criteria for eligibility under the healthy 30 Iowa plan, which provides that an individual 19 through 64 31 years of age is eligible if the individual is a United States 32 citizen, is a resident of Iowa, provides a social security 33 number upon application for the plan, has household income at 34 or below 100 percent of the FPL, and fulfills other conditions 35 -16- LSB 2517YC (11) 85 pf/rj 16/ 21

H.F. _____ of participation in the plan described in the Code chapter, 1 including member financial participation requirements. 2 Additionally, individuals otherwise eligible solely for family 3 planning benefits authorized under the medical assistance 4 family planning services waiver may be eligible. Eligibility 5 under the healthy Iowa plan is to be implemented in a manner 6 that ensures that the healthy Iowa plan is the payor of 7 last resort. Individuals who are not eligible include an 8 individual eligible as a full benefits recipient under the 9 medical assistance program, an individual who is a recipient of 10 Medicare, an individual who is pregnant and otherwise eligible 11 for the medical assistance program, and an individual who is 12 eligible for benefits through the United States department of 13 veterans affairs. 14 An applicant for the plan must provide all insurance 15 information required by the health insurance premium payment 16 program, and the department may elect to pay for the costs 17 of premiums for applicants with access to employer-sponsored 18 health care coverage if the department determines such payment 19 to be cost-effective. 20 Following initial enrollment, a member is eligible for 21 the healthy Iowa plan for 12 months, subject to program 22 termination and other limitations otherwise specified in 23 the bill. Eligibility is required to be reviewed at least 24 annually. Upon enrollment, a member is required to choose a 25 primary medical provider within the accountable care provider 26 network. If the member does not choose a primary medical 27 provider, the department is required to assign the member to a 28 primary medical provider pursuant to the department’s mandatory 29 enrollment provisions and in accordance with quality data 30 available to the department. A member is required to have a 31 choice of primary medical providers, subject to the limitations 32 under the bill and subject to the results of attribution of 33 members to an accountable care organization (ACO). The bill 34 authorizes DHS to contract with a third-party administrator to 35 -17- LSB 2517YC (11) 85 pf/rj 17/ 21

H.F. _____ administer the plan. 1 The bill provides that covered benefits under the plan are 2 to include benefits that meet the requirements of alternative 3 benefit plans under section 1937 of the federal Social Security 4 Act as modified by section 1302 of the Affordable Care Act, and 5 shall, at a minimum, include essential health benefits. The 6 bill specifies benefits that are covered services under the 7 accountable care plan. 8 The bill directs DHS to develop a provider network by 9 partitioning the state into regions. The accountable care 10 provider network includes all providers enrolled in the 11 medical assistance program as a healthy Iowa plan provider. 12 Reimbursement to healthy Iowa plan providers is only to be made 13 for covered benefits specified under the bill. Each region in 14 the accountable care provider network must include at least 15 one accountable care organization with which the department 16 contracts to ensure the coordination and management of the 17 health of the members within the region, to produce improved 18 health care quality, and to control overall cost. The acute 19 care teaching hospital in a county with a population over 20 350,000 is designated as the accountable care organization for 21 the region specified by the department. The bill provides 22 requirement for ACOs including qualifications, contracting 23 processes, and contract terms; a methodology for attribution 24 of a specified member population to the ACO; accountability 25 for quality performance and total cost of care metrics for an 26 attributed population; risk sharing; and a requirement that 27 a primary medical provider participating in the accountable 28 care provider network contract with the ACO responsible 29 for the region for the purposes of member coordination of 30 care. The bill establishes limitations on member choice of 31 providers including limitations due to attribution, and limits 32 on accessing services not provided by the ACO without prior 33 approval of the ACO. The bill provides for reimbursement 34 both of healthy Iowa plan providers and ACOs. The bill also 35 -18- LSB 2517YC (11) 85 pf/rj 18/ 21

H.F. _____ provides for exchange of member health information among the 1 member’s healthy Iowa plan providers to facilitate coordination 2 and management of care, improved health outcomes, and reduction 3 in costs. The bill directs DHS to provide a member’s health 4 care claims data to the member’s ACO. 5 The bill requires member financial participation in the 6 form of contributions, deductibles, and copayments based on 7 household income and ability to pay. A member must pay the 8 initial monthly contribution prior to receiving any benefits 9 under the plan. Payment of monthly contributions, within 10 60 days of the date the payment is due, is a condition of 11 membership, and nonpayment is grounds for disenrollment 12 from the plan. A member may request a hardship exemption 13 from payment of the monthly contribution, and the monthly 14 contribution may be waived for a member with a household income 15 between zero and 50 percent of the FPL, upon completion of 16 the health risk assessment, annual physical, and preventive 17 services specified in the bill. Contributions collected are to 18 be deposited in the member’s my health rewards account. 19 The bill directs DHS to establish a my health rewards account 20 for each healthy Iowa plan member. Moneys in a member’s 21 account must be used only to improve the health of a member. 22 In addition, the bill specifies that financial incentives 23 established by rule are to be made to a member’s account by the 24 plan for completion of a health risk assessment, completion of 25 an annual physical, receipt of preventive services specified 26 by the plan, and an amount that is the difference between the 27 sum of the required contributions made by the member and the 28 amounts deposited by the plan and the total annual deductible 29 for the member. The member may be subject to forfeiture of the 30 moneys in the account for failure to pay required contributions 31 or cost-sharing amounts, or a pattern of inappropriate use of 32 emergency department or other benefits. The bill also provides 33 for the use of any moneys remaining in a member’s my health 34 rewards account, annually, at the end of a 12-month enrollment 35 -19- LSB 2517YC (11) 85 pf/rj 19/ 21