Senate
File
2213
-
Introduced
SENATE
FILE
2213
BY
COMMITTEE
ON
HUMAN
RESOURCES
(SUCCESSOR
TO
SF
2107)
A
BILL
FOR
An
Act
relating
to
Medicaid
program
improvement,
and
including
1
effective
date
and
retroactive
applicability
provisions.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
3
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Section
1.
LEGISLATIVE
FINDINGS
——
GOALS
AND
INTENT.
1
1.
The
general
assembly
finds
all
of
the
following:
2
a.
In
the
majority
of
states,
Medicaid
managed
care
has
3
been
introduced
on
an
incremental
basis,
beginning
with
the
4
enrollment
of
low-income
children
and
parents
and
proceeding
5
in
stages
to
include
nonelderly
persons
with
disabilities
and
6
older
individuals.
Iowa,
unlike
the
majority
of
states,
is
7
implementing
Medicaid
managed
care
hastily
and
simultaneously
8
across
a
broad
and
diverse
population
that
includes
individuals
9
with
complex
health
care
and
long-term
services
and
supports
10
needs,
making
these
individuals
especially
vulnerable
to
11
receiving
inappropriate,
inadequate,
or
substandard
services
12
and
supports.
13
b.
The
success
or
failure
of
Medicaid
managed
care
in
Iowa
14
depends
on
proper
strategic
planning
and
strong
oversight,
and
15
the
incorporation
of
the
core
values,
principles,
and
goals
16
of
the
strategic
plan
into
Medicaid
managed
care
contractual
17
obligations.
While
Medicaid
managed
care
techniques
may
create
18
pathways
and
offer
opportunities
toward
quality
improvement
and
19
predictability
in
costs,
if
cost
savings
and
administrative
20
efficiencies
are
the
primary
goals,
Medicaid
managed
care
may
21
instead
erect
new
barriers
and
limit
the
care
and
support
22
options
available,
especially
to
high-need,
vulnerable
Medicaid
23
recipients.
A
well-designed
strategic
plan
and
effective
24
oversight
ensure
that
cost
savings,
improved
health
outcomes,
25
and
efficiencies
are
not
achieved
at
the
expense
of
diminished
26
program
integrity,
a
reduction
in
the
quality
or
availability
27
of
services,
or
adverse
consequences
to
the
health
and
28
well-being
of
Medicaid
recipients.
29
c.
Strategic
planning
should
include
all
of
the
following:
30
(1)
Guidance
in
establishing
and
maintaining
a
robust
31
and
appropriate
workforce
and
a
provider
network
capable
of
32
addressing
all
of
the
diverse,
distinct,
and
wide-ranging
33
treatment
and
support
needs
of
Medicaid
recipients.
34
(2)
Developing
a
sound
methodology
for
establishing
and
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adjusting
capitation
rates
to
account
for
all
essential
costs
1
involved
in
treating
and
supporting
the
entire
spectrum
of
2
needs
across
recipient
populations.
3
(3)
Addressing
the
sufficiency
of
information
and
data
4
resources
to
enable
review
of
factors
such
as
utilization,
5
service
trends,
system
performance,
and
outcomes.
6
(4)
Building
effective
working
relationships
and
developing
7
strategies
to
support
community-level
integration
that
provides
8
cross-system
coordination
and
synchronization
among
the
various
9
service
sectors,
providers,
agencies,
and
organizations
to
10
further
holistic
well-being
and
population
health
goals.
11
d.
While
the
contracts
entered
into
between
the
state
12
and
managed
care
organizations
function
as
a
mechanism
for
13
enforcing
requirements
established
by
the
federal
and
state
14
governments
and
allow
states
to
shift
the
financial
risk
15
associated
with
caring
for
Medicaid
recipients
to
these
16
contractors,
the
state
ultimately
retains
responsibility
for
17
the
Medicaid
program
and
the
oversight
of
the
performance
of
18
the
program’s
contractors.
Administration
of
the
Medicaid
19
program
benefits
by
managed
care
organizations
should
not
be
20
viewed
by
state
policymakers
and
state
agencies
as
a
means
of
21
divesting
themselves
of
their
constitutional
and
statutory
22
responsibilities
to
ensure
that
recipients
of
publicly
funded
23
services
and
supports,
as
well
as
taxpayers
in
general,
are
24
effectively
served.
25
e.
Overseeing
the
performance
of
Medicaid
managed
care
26
contractors
requires
a
different
set
of
skills
than
those
27
required
for
administering
a
fee-for-service
program.
In
the
28
absence
of
the
in-house
capacity
of
the
department
of
human
29
services
to
perform
tasks
specific
to
Medicaid
managed
care
30
oversight,
the
state
essentially
cedes
its
responsibilities
31
to
private
contractors
and
relinquishes
its
accountability
32
to
the
public.
In
order
to
meet
these
responsibilities,
33
state
policymakers
must
ensure
that
the
state,
including
the
34
department
of
human
services
as
the
state
Medicaid
agency,
has
35
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the
authority
and
resources,
including
the
adequate
number
of
1
qualified
personnel
and
the
necessary
tools,
to
carry
out
these
2
responsibilities,
provide
effective
administration,
and
ensure
3
accountability
and
compliance.
4
f.
State
policymakers
must
also
ensure
that
Medicaid
5
managed
care
contracts
contain,
at
a
minimum,
clear,
6
unambiguous
performance
standards,
operating
guidelines,
7
data
collection,
maintenance,
retention,
and
reporting
8
requirements,
and
outcomes
expectations
so
that
contractors
9
and
subcontractors
are
held
accountable
to
clear
contract
10
specifications.
11
g.
As
with
all
system
and
program
redesign
efforts
12
undertaken
in
the
state
to
date,
the
assumption
of
the
13
administration
of
Medicaid
program
benefits
by
managed
care
14
organizations
must
involve
ongoing
stakeholder
input
and
15
earn
the
trust
and
support
of
these
stakeholders.
Medicaid
16
recipients,
providers,
advocates,
and
other
stakeholders
have
17
intimate
knowledge
of
the
people
and
processes
involved
in
18
ensuring
the
health
and
safety
of
Medicaid
recipients,
and
are
19
able
to
offer
valuable
insight
into
the
barriers
likely
to
be
20
encountered
as
well
as
propose
solutions
for
overcoming
these
21
obstacles.
Local
communities
and
providers
of
services
and
22
supports
have
firsthand
experience
working
with
the
Medicaid
23
recipients
they
serve
and
are
able
to
identify
factors
that
24
must
be
considered
to
make
a
system
successful.
Agencies
and
25
organizations
that
have
specific
expertise
and
experience
with
26
the
services
and
supports
needs
of
Medicaid
recipients
and
27
their
families
are
uniquely
placed
to
provide
needed
assistance
28
in
developing
the
measures
for
and
in
evaluating
the
quality
29
of
the
program.
30
2.
It
is
the
intent
of
the
general
assembly
that
the
31
Medicaid
program
be
implemented
and
administered,
including
32
through
Medicaid
managed
care
policies
and
contract
provisions,
33
in
a
manner
that
safeguards
the
interests
of
Medicaid
34
recipients,
encourages
the
participation
of
Medicaid
providers,
35
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and
protects
the
interests
of
all
taxpayers,
while
attaining
1
the
goals
of
Medicaid
modernization
to
improve
quality
and
2
access,
promote
accountability
for
outcomes,
and
create
a
more
3
predictable
and
sustainable
Medicaid
budget.
4
REVIEW
OF
PROGRAM
INTEGRITY
DUTIES
5
Sec.
2.
REVIEW
OF
PROGRAM
INTEGRITY
DUTIES
——
WORKGROUP
——
6
REPORT.
7
1.
The
director
of
human
services
shall
convene
a
8
workgroup
comprised
of
members
including
the
commissioner
9
of
insurance,
the
auditor
of
state,
the
Medicaid
director
10
and
bureau
chiefs
of
the
managed
care
organization
oversight
11
and
supports
bureau,
the
Iowa
Medicaid
enterprise
support
12
bureau,
and
the
medical
and
long-term
services
and
supports
13
bureau,
and
a
representative
of
the
program
integrity
unit,
14
or
their
designees;
and
representatives
of
other
appropriate
15
state
agencies
or
other
entities
including
but
not
limited
to
16
the
office
of
the
attorney
general,
the
office
of
long-term
17
care
ombudsman,
and
the
Medicaid
fraud
control
unit
of
the
18
investigations
division
of
the
department
of
inspections
and
19
appeals.
The
workgroup
shall
do
all
of
the
following:
20
a.
Review
the
duties
of
each
entity
with
responsibilities
21
relative
to
Medicaid
program
integrity
and
managed
care
22
organizations;
review
state
and
federal
laws,
regulations,
23
requirements,
guidance,
and
policies
relating
to
Medicaid
24
program
integrity
and
managed
care
organizations;
and
review
25
the
laws
of
other
states
relating
to
Medicaid
program
integrity
26
and
managed
care
organizations.
The
workgroup
shall
determine
27
areas
of
duplication,
fragmentation,
and
gaps;
shall
identify
28
possible
integration,
collaboration
and
coordination
of
duties;
29
and
shall
determine
whether
existing
general
state
Medicaid
30
program
and
fee-for-service
policies,
laws,
and
rules
are
31
sufficient,
or
if
changes
or
more
specific
policies,
laws,
and
32
rules
are
required
to
provide
for
comprehensive
and
effective
33
administration
and
oversight
of
the
Medicaid
program.
34
b.
Review
historical
uses
of
the
Medicaid
fraud
fund
created
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in
section
249A.50
and
make
recommendations
for
future
uses
1
of
the
moneys
in
the
fund
and
any
changes
in
law
necessary
to
2
adequately
address
program
integrity.
3
c.
Review
medical
loss
ratio
provisions
relative
to
4
Medicaid
managed
care
contracts
and
make
recommendations
5
regarding,
at
a
minimum,
requirements
for
the
necessary
6
collection,
maintenance,
retention,
reporting,
and
sharing
of
7
data
and
information
by
Medicaid
managed
care
organizations
8
for
effective
determination
of
compliance,
and
to
identify
9
the
costs
and
activities
that
should
be
included
in
the
10
calculation
of
administrative
costs,
medical
costs
or
benefit
11
expenses,
health
quality
improvement
costs,
and
other
costs
and
12
activities
incidental
to
the
determination
of
a
medical
loss
13
ratio.
14
d.
Review
the
capacity
of
state
agencies,
including
the
need
15
for
specialized
training
and
expertise,
to
address
Medicaid
16
and
managed
care
organization
program
integrity
and
provide
17
recommendations
for
the
provision
of
necessary
resources
and
18
infrastructure,
including
annual
budget
projections.
19
e.
Review
the
incentives
and
penalties
applicable
to
20
violations
of
program
integrity
requirements
to
determine
their
21
adequacy
in
combating
waste,
fraud,
abuse,
and
other
violations
22
that
divert
limited
resources
that
would
otherwise
be
expended
23
to
safeguard
the
health
and
welfare
of
Medicaid
recipients,
24
and
make
recommendations
for
necessary
adjustments
to
improve
25
compliance.
26
f.
Make
recommendations
regarding
the
quarterly
and
annual
27
auditing
of
financial
reports
required
to
be
performed
for
28
each
Medicaid
managed
care
organization
to
ensure
that
the
29
activities
audited
provide
sufficient
information
to
the
30
division
of
insurance
of
the
department
of
commerce
and
the
31
department
of
human
services
to
ensure
program
integrity.
The
32
recommendations
shall
also
address
the
need
for
additional
33
audits
or
other
reviews
of
managed
care
organizations.
34
2.
The
department
of
human
services
shall
submit
a
report
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2213
of
the
workgroup
to
the
governor
and
the
general
assembly
1
on
or
before
November
15,
2016,
to
provide
findings
and
2
recommendations
for
a
coordinated
approach
to
comprehensive
and
3
effective
administration
and
oversight
of
the
Medicaid
program.
4
MEDICAID
REINVESTMENT
FUND
5
Sec.
3.
NEW
SECTION
.
249A.4C
Medicaid
reinvestment
fund.
6
1.
A
Medicaid
reinvestment
fund
is
created
in
the
state
7
treasury
under
the
authority
of
the
department.
Moneys
from
8
savings
realized
from
the
movement
of
Medicaid
recipients
from
9
institutional
settings
to
home
and
community-based
services,
10
the
portion
of
the
capitation
rate
withheld
from
and
not
11
returned
to
Medicaid
managed
care
organizations
at
the
end
12
of
each
fiscal
year,
any
recouped
excess
of
capitation
rates
13
paid
to
Medicaid
managed
care
organizations,
any
overpayments
14
recovered
under
Medicaid
managed
care
contracts,
and
any
other
15
savings
realized
from
Medicaid
managed
care
or
from
Medicaid
16
program
cost-containment
efforts,
shall
be
credited
to
the
17
Medicaid
reinvestment
fund.
18
2.
Notwithstanding
section
8.33,
moneys
credited
to
19
the
fund
from
any
other
account
or
fund
shall
not
revert
to
20
the
other
account
or
fund.
Moneys
in
the
fund
shall
only
21
be
used
as
provided
in
appropriations
from
the
fund
for
22
the
Medicaid
program
and
for
health
system
transformation
23
and
integration,
including
but
not
limited
to
providing
24
the
necessary
infrastructure
and
resources
to
protect
the
25
interests
of
Medicaid
recipients,
maintaining
adequate
provider
26
participation,
and
ensuring
program
integrity.
Such
uses
may
27
include
but
are
not
limited
to:
28
a.
Ensuring
appropriate
reimbursement
of
Medicaid
29
providers
to
maintain
the
type
and
number
of
appropriately
30
trained
providers
necessary
to
address
the
needs
of
Medicaid
31
recipients.
32
b.
Providing
home
and
community-based
services
as
necessary
33
to
rebalance
the
long-term
services
and
supports
infrastructure
34
and
to
reduce
Medicaid
home
and
community-based
services
waiver
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waiting
lists.
1
c.
Ensuring
that
a
fully
functioning
independent
long-term
2
services
and
supports
ombudsman
program
is
available
to
provide
3
advocacy
services
and
assistance
to
Medicaid
recipients.
4
d.
Ensuring
adequate
and
appropriate
capacity
of
the
5
department
of
human
services
as
the
single
state
agency
6
designated
to
administer
and
supervise
the
administration
of
7
the
Medicaid
program,
to
ensure
compliance
with
state
and
8
federal
law
and
program
integrity
requirements.
9
e.
Addressing
workforce
issues
to
ensure
a
competent,
10
diverse,
and
sustainable
health
care
workforce
and
to
11
improve
access
to
health
care
in
underserved
areas
and
among
12
underserved
populations,
recognizing
long-term
services
and
13
supports
as
an
essential
component
of
the
health
care
system.
14
f.
Supporting
innovation,
longer-term
community
15
investments,
and
the
activities
of
local
public
health
16
agencies,
aging
and
disability
resource
centers
and
service
17
agencies,
mental
health
and
disability
services
regions,
social
18
services,
and
child
welfare
entities
and
other
providers
of
19
and
advocates
for
services
and
supports
to
encourage
health
20
system
transformation
and
integration
through
a
broad
range
of
21
prevention
strategies
and
population-based
approaches
to
meet
22
the
holistic
needs
of
the
population
as
a
whole.
23
3.
The
department
shall
establish
a
mechanism
to
measure
and
24
certify
the
amount
of
savings
resulting
from
Medicaid
managed
25
care
and
Medicaid
program
cost-containment
activities
and
shall
26
ensure
that
such
realized
savings
are
credited
to
the
fund
and
27
used
as
provided
in
appropriations
from
the
fund.
28
LONG-TERM
SERVICES
AND
SUPPORTS
OMBUDSMAN
29
Sec.
4.
Section
231.44,
subsection
1,
Code
2016,
is
amended
30
by
adding
the
following
new
paragraphs:
31
NEW
PARAGRAPH
.
d.
Accessing
the
results
of
a
review
32
of
a
level
of
care
or
a
needs-based
eligibility
assessment
33
or
reassessment
by
a
managed
care
organization
in
which
34
the
managed
care
organization
recommends
denial
or
limited
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authorization
of
a
service,
including
the
type
or
level
1
of
service,
the
reduction,
suspension,
or
termination
of
a
2
previously
authorized
service,
or
a
change
in
level
of
care,
3
upon
the
request
of
the
individual
receiving
long-term
services
4
and
supports.
5
NEW
PARAGRAPH
.
e.
Receiving
and
reviewing
for
Medicaid
6
recipients
who
receive
long-term
services
and
supports
notices
7
of
disenrollment
from
a
managed
care
organization
or
notices
8
that
would
result
in
a
change
in
such
recipient’s
level
of
care
9
setting,
including
involuntary
and
voluntary
discharges
or
10
transfers
of
a
recipient.
11
Sec.
5.
Section
231.44,
Code
2016,
is
amended
by
adding
the
12
following
new
subsections:
13
NEW
SUBSECTION
.
3A.
The
office
of
long-term
care
ombudsman
14
and
representatives
of
the
office,
when
providing
assistance
15
and
advocacy
services
authorized
under
this
section,
shall
be
16
considered
a
health
oversight
agency
as
defined
in
45
C.F.R.
17
§164.501
for
the
purposes
of
health
oversight
activities
18
as
described
in
45
C.F.R.
§164.512(d)
including
access
to
19
Medicaid
recipients’
health
records
and
other
appropriate
20
information,
including
from
the
department
of
human
services
21
or
the
applicable
Medicaid
managed
care
organization,
as
22
necessary
to
fulfill
the
duties
specified
under
this
section.
23
The
department
of
human
services,
in
collaboration
with
the
24
office
of
long-term
care
ombudsman,
shall
adopt
rules
to
ensure
25
compliance
by
affected
entities
with
this
subsection
and
to
26
ensure
recognition
of
the
office
of
long-term
care
ombudsman
27
as
a
duly
authorized
and
identified
agent
or
representative
of
28
the
state.
29
NEW
SUBSECTION
.
3B.
The
department
of
human
services
and
30
Medicaid
managed
care
organizations
shall
inform
Medicaid
31
recipients
of
the
advocacy
services
and
assistance
available
32
through
the
office
of
long-term
care
ombudsman
and
shall
33
provide
contact
and
other
information
regarding
the
advocacy
34
services
and
assistance
to
Medicaid
recipients
as
directed
by
35
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the
office
of
long-term
care
ombudsman.
1
NEW
SUBSECTION
.
3C.
The
office
of
long-term
care
ombudsman
2
shall
act
as
an
independent
agency
in
providing
advocacy
3
services
and
assistance
under
this
section.
The
office
of
4
long-term
care
ombudsman
shall,
in
addition
to
other
duties
5
prescribed
and,
at
a
minimum,
do
all
of
the
following
in
6
the
furtherance
of
the
provision
of
advocacy
services
and
7
assistance
under
this
section:
8
a.
Represent
the
interests
of
Medicaid
program
recipients
9
before
governmental
agencies
and
seek
administrative,
legal,
10
and
other
remedies
for
the
recipient.
11
b.
Analyze,
comment
on,
and
monitor
the
development
and
12
implementation
of
federal,
state,
and
local
laws,
regulations,
13
and
other
governmental
policies
and
actions,
and
recommend
14
any
changes
in
such
laws,
policies,
and
actions
as
determined
15
appropriate
by
the
office
of
long-term
care
ombudsman.
16
Sec.
6.
NEW
SECTION
.
231.44A
Willful
interference
with
17
duties
related
to
long-term
services
and
supports
——
penalty.
18
Willful
interference
with
a
representative
of
the
office
of
19
long-term
care
ombudsman
in
the
performance
of
official
duties
20
in
accordance
with
section
231.44
is
a
violation
of
section
21
231.44,
subject
to
a
penalty
prescribed
by
rule.
The
office
22
of
long-term
care
ombudsman
shall
adopt
rules
specifying
the
23
amount
of
a
penalty
imposed,
consistent
with
the
penalties
24
imposed
under
section
231.42,
subsection
8,
and
specifying
25
procedures
for
notice
and
appeal
of
penalties
imposed.
Any
26
moneys
collected
pursuant
to
this
section
shall
be
deposited
in
27
the
Medicaid
reinvestment
fund
created
in
section
249A.4C.
28
MEDICAL
ASSISTANCE
ADVISORY
COUNCIL
29
Sec.
7.
Section
249A.4B,
subsection
1,
Code
2016,
is
amended
30
to
read
as
follows:
31
1.
A
medical
assistance
advisory
council
is
created
to
32
comply
with
42
C.F.R.
§431.12
based
on
section
1902(a)(4)
of
33
the
federal
Social
Security
Act
and
to
advise
the
director
34
about
health
and
medical
care
services
under
the
medical
35
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assistance
program.
The
council
shall
meet
no
more
than
at
1
least
quarterly.
The
director
of
public
health
shall
serve
as
2
chairperson
of
the
council.
3
Sec.
8.
Section
249A.4B,
subsection
2,
paragraph
b,
Code
4
2016,
is
amended
to
read
as
follows:
5
b.
Public
representatives
which
may
include
members
of
6
consumer
groups,
including
recipients
of
medical
assistance
or
7
their
families,
consumer
organizations,
and
others,
which
shall
8
be
appointed
by
the
governor
in
equal
in
number
to
the
number
9
of
representatives
of
the
professional
and
business
entities
10
specifically
represented
under
paragraph
“a”
,
appointed
by
the
11
governor
for
staggered
terms
of
two
years
each,
none
of
whom
12
shall
be
members
of,
or
practitioners
of,
or
have
a
pecuniary
13
interest
in
any
of
the
professional
or
business
entities
14
specifically
represented
under
paragraph
“a”
,
and
a
majority
15
of
whom
shall
be
current
or
former
recipients
of
medical
16
assistance
or
members
of
the
families
of
current
or
former
17
recipients.
18
Sec.
9.
Section
249A.4B,
subsection
2,
Code
2016,
is
amended
19
by
adding
the
following
new
paragraph:
20
NEW
PARAGRAPH
.
0g.
The
state
long-term
care
ombudsman
or
21
the
ombudsman’s
designee.
22
Sec.
10.
Section
249A.4B,
subsection
3,
paragraph
a,
Code
23
2016,
is
amended
by
adding
the
following
new
subparagraph:
24
NEW
SUBPARAGRAPH
.
(4)
The
state
long-term
care
ombudsman
or
25
the
ombudsman’s
designee.
26
Sec.
11.
Section
249A.4B,
subsection
3,
paragraph
c,
Code
27
2016,
is
amended
to
read
as
follows:
28
c.
Based
upon
the
deliberations
of
the
council
,
and
the
29
executive
committee
,
and
the
subcommittees
,
the
executive
30
committee
and
the
subcommittees,
respectively,
shall
make
31
recommendations
to
the
director
regarding
the
budget,
policy,
32
and
administration
of
the
medical
assistance
program.
33
Sec.
12.
Section
249A.4B,
Code
2016,
is
amended
by
adding
34
the
following
new
subsections:
35
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NEW
SUBSECTION
.
3A.
a.
The
council
shall
create
1
the
following
subcommittees,
and
may
create
additional
2
subcommittees
as
necessary
to
address
medical
assistance
3
program
policies,
administration,
budget,
and
other
factors
and
4
issues:
5
(1)
The
stakeholder
safeguards
subcommittee,
for
which
6
the
co-chairpersons
shall
be
a
member
of
the
council
who
is
a
7
current
recipient
or
family
member
of
a
recipient
of
medical
8
assistance
or
who
represents
a
consumer
advocacy
entity,
and
a
9
member
of
the
council
who
represents
a
professional
or
business
10
entity,
both
selected
by
the
executive
committee.
The
mission
11
of
the
stakeholder
safeguards
subcommittee
is
to
provide
for
12
ongoing
stakeholder
engagement
and
feedback
on
issues
affecting
13
Medicaid
recipients,
providers,
and
other
stakeholders.
14
(2)
The
long-term
services
and
supports
subcommittee
15
which
shall
be
chaired
by
the
state
long-term
care
ombudsman,
16
or
the
ombudsman’s
designee.
The
mission
of
the
long-term
17
services
and
supports
subcommittee
is
to
be
a
resource
for
18
the
council
and
advise
the
department
on
policy
development
19
and
program
administration
relating
to
Medicaid
long-term
20
services
and
support
including
but
not
limited
to
developing
21
outcomes
and
performance
measures
for
Medicaid
managed
care
22
for
the
long-term
services
and
supports
population;
addressing
23
issues
related
to
home
and
community-based
services
waivers
and
24
waiting
lists;
and
reviewing
the
system
of
long-term
services
25
and
supports
to
ensure
provision
of
home
and
community-based
26
services
and
the
rebalancing
of
the
health
care
infrastructure
27
in
accordance
with
state
and
federal
law
including
but
not
28
limited
to
the
principles
established
in
Olmstead
v.
L.C.,
527
29
U.S.
581
(1999)
and
the
federal
Americans
with
Disabilities
Act
30
and
in
a
manner
that
reflects
a
sustainable,
person-centered
31
approach
to
improve
health
and
life
outcomes,
supports
32
maximum
independence,
addresses
medical
and
social
needs
in
a
33
coordinated,
integrated
manner,
and
provides
for
sufficient
34
resources
including
a
stable,
well-qualified
workforce.
35
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(3)
The
transparency,
data,
and
program
evaluation
1
subcommittee
which
shall
be
chaired
by
the
director
of
the
2
university
of
Iowa
public
policy
center,
or
the
director’s
3
designee.
The
mission
of
the
transparency,
data,
and
program
4
evaluation
subcommittee
is
to
ensure
Medicaid
program
5
transparency;
ensure
the
collection,
maintenance,
retention,
6
reporting,
and
analysis
of
sufficient
and
meaningful
data
7
to
inform
policy
development
and
program
effectiveness;
8
support
development
and
administration
of
a
consumer-friendly
9
dashboard;
and
promote
the
ongoing
evaluation
of
Medicaid
10
recipient
and
provider
satisfaction
with
the
Medicaid
program.
11
(4)
The
program
integrity
subcommittee
which
shall
be
12
chaired
by
the
Medicaid
director,
or
the
director’s
designee.
13
The
mission
of
the
program
integrity
subcommittee
is
to
ensure
14
that
a
comprehensive
system
including
specific
policies,
laws,
15
and
rules
and
adequate
resources
and
measures
are
in
place
to
16
effectively
administer
the
program
and
to
maintain
compliance
17
with
federal
and
state
program
integrity
requirements.
18
b.
The
chairperson
of
the
council
shall
appoint
members
to
19
each
subcommittee
from
the
general
membership
of
the
council.
20
Consideration
in
appointing
subcommittee
members
shall
include
21
the
individual’s
knowledge
about,
and
interest
or
expertise
in,
22
matters
that
come
before
the
subcommittee.
23
c.
Subcommittees
shall
meet
at
the
call
of
the
chairperson
24
of
the
subcommittee
or
at
the
request
of
a
majority
of
the
25
members
of
the
subcommittee.
26
NEW
SUBSECTION
.
7.
The
council,
executive
committee,
and
27
subcommittees
shall
jointly
submit
a
report
to
the
governor
and
28
the
general
assembly
by
January
1,
annually,
summarizing
the
29
outcomes
and
findings
of
their
respective
deliberations
and
any
30
recommendations
including
but
not
limited
to
those
for
changes
31
in
law
or
policy.
32
NEW
SUBSECTION
.
8.
The
council,
executive
committee,
33
and
subcommittees
may
enlist
the
services
of
persons
who
are
34
qualified
by
education,
expertise,
or
experience
to
advise,
35
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consult
with,
or
otherwise
assist
the
council,
executive
1
committee,
or
subcommittees
in
the
performance
of
their
2
duties.
The
council,
executive
committee,
or
subcommittees
3
may
specifically
enlist
the
assistance
of
entities
such
as
the
4
university
of
Iowa
public
policy
center
to
provide
ongoing
5
evaluation
of
the
Medicaid
program
and
to
make
evidence-based
6
recommendations
to
improve
the
program.
The
council,
executive
7
committee,
and
subcommittees
shall
enlist
input
from
the
8
patient-centered
health
advisory
council
created
in
section
9
135.159,
the
mental
health
and
disabilities
services
commission
10
created
in
section
225C.5,
the
commission
on
aging
created
in
11
section
231.11,
the
bureau
of
substance
abuse
of
the
department
12
of
public
health,
and
other
appropriate
state
and
local
13
entities
to
provide
advice
to
the
council,
executive
committee,
14
and
subcommittees.
15
Sec.
13.
Section
249A.4B,
subsections
4,
5,
and
6,
Code
16
2016,
are
amended
to
read
as
follows:
17
4.
For
each
council
meeting,
other
than
those
held
during
18
the
time
the
general
assembly
is
in
session,
each
legislative
19
member
of
the
council
shall
be
reimbursed
for
actual
travel
20
and
other
necessary
expenses
and
shall
receive
a
per
diem
as
21
specified
in
section
7E.6
for
each
day
in
attendance,
as
shall
22
the
members
of
the
council
,
or
the
executive
committee
,
or
23
a
subcommittee
who
are
recipients
or
the
family
members
of
24
recipients
of
medical
assistance,
regardless
of
whether
the
25
general
assembly
is
in
session.
26
5.
The
department
shall
provide
staff
support
and
27
independent
technical
assistance
to
the
council
,
and
the
28
executive
committee
,
and
the
subcommittees
.
29
6.
The
director
shall
consider
the
recommendations
30
offered
by
the
council
,
and
the
executive
committee
,
and
31
the
subcommittees
in
the
director’s
preparation
of
medical
32
assistance
budget
recommendations
to
the
council
on
human
33
services
pursuant
to
section
217.3
and
in
implementation
of
34
medical
assistance
program
policies.
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HEALTH
RESOURCES
AND
INFRASTRUCTURE
1
Sec.
14.
PATIENT-CENTERED
HEALTH
ADVISORY
COUNCIL
——
2
ASSESSMENT
OF
HEALTH
RESOURCES
AND
INFRASTRUCTURE.
3
1.
The
patient-centered
health
advisory
council
created
4
in
section
135.159
shall
assess
the
capacity
of
the
health
5
care
infrastructure
and
resources
in
the
state
and
recommend
6
more
appropriate
alignment
with
broad
systems
changes,
the
7
increasing
array
of
care
delivery
models
such
as
the
expansion
8
of
Medicaid
managed
care,
accountable
care
organizations,
and
9
public
health
modernization,
and
a
more
integrated,
holistic,
10
prevention-based
and
population-based
approach
to
health
and
11
health
care.
The
assessment
shall
also
address
the
sufficiency
12
and
proficiency
of
the
existing
health-related
workforce
and
13
the
potential
of
braiding
and
blending
funding
streams
to
14
support
the
holistic
needs
of
the
population.
15
2.
Initially,
the
council
shall
do
all
of
the
following:
16
a.
Assess
the
potential
for
integration
and
coordination
17
of
various
service
delivery
sectors
including
public
health,
18
aging
and
disability
services
agencies,
mental
health
and
19
disability
services
regions,
social
services,
child
welfare,
20
and
other
such
sectors
and
shall
make
recommendations
for
21
such
integration
and
coordination
to
more
efficiently
and
22
effectively
address
consumer
needs.
23
b.
Assess
funding
streams,
including
Medicaid
funding,
24
and
make
recommendations
to
blend
or
braid
funding
to
support
25
prevention
and
population
health
strategies
in
addressing
the
26
holistic
well-being
of
consumers.
27
c.
Assess
current
and
projected
health
workforce
28
availability
to
determine
the
most
efficient
application
29
and
utilization
of
the
roles,
functions,
responsibilities,
30
activities,
and
decision-making
capacity
of
health
care
31
professionals
and
other
allied
and
support
personnel,
and
make
32
recommendations
for
improvement
and
alternative
modes
of
health
33
care
delivery.
34
3.
The
council
shall
submit
a
report
of
its
findings
and
35
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recommendations
regarding
the
initial
assessments
specified
1
in
subsection
2
to
the
governor
and
the
general
assembly
by
2
January
1,
2017.
The
council
shall
submit
subsequent
reports
3
relating
to
additional
assessments
of
and
recommendations
4
relating
to
the
health
care
infrastructure
and
resources
on
or
5
before
January
1,
annually,
thereafter.
6
MEDICAID
PROGRAM
POLICY
IMPROVEMENT
7
Sec.
15.
DIRECTIVES
FOR
MEDICAID
PROGRAM
POLICY
8
IMPROVEMENTS.
In
order
to
safeguard
the
interests
of
Medicaid
9
recipients,
encourage
the
participation
of
Medicaid
providers,
10
and
protect
the
interests
of
all
taxpayers,
the
department
of
11
human
services
shall
comply
with
or
ensure
that
the
specified
12
entity
complies
with
all
of
the
following
and
shall
amend
13
Medicaid
managed
care
contract
provisions
as
necessary
to
14
reflect
all
of
the
following:
15
1.
CONSUMER
PROTECTIONS.
16
a.
In
accordance
with
42
C.F.R.
§438.420,
a
Medicaid
managed
17
care
organization
shall
continue
a
recipient’s
benefits
during
18
an
appeal
process.
If,
as
allowed
when
final
resolution
of
19
an
appeal
is
adverse
to
the
Medicaid
recipient,
the
Medicaid
20
managed
care
organization
chooses
to
recover
the
costs
of
the
21
services
furnished
to
the
recipient
while
an
appeal
is
pending,
22
the
Medicaid
managed
care
organization
shall
provide
adequate
23
prior
notice
of
potential
recovery
of
costs
to
the
recipient
at
24
the
time
the
appeal
is
filed,
and
any
costs
recovered
shall
be
25
remitted
to
the
department
of
human
services
and
deposited
in
26
the
Medicaid
reinvestment
fund
created
in
section
249A.4C.
27
b.
Ensure
that
each
Medicaid
managed
care
organization
28
provides,
at
a
minimum,
all
the
benefits
and
services
deemed
29
medically
necessary
that
were
covered,
including
to
the
30
extent
and
in
the
same
manner
and
subject
to
the
same
prior
31
authorization
criteria,
by
the
state
program
directly
under
32
fee
for
service
prior
to
January
1,
2016.
Benefits
covered
33
through
Medicaid
managed
care
shall
comply
with
the
specific
34
requirements
in
state
law
applicable
to
the
respective
Medicaid
35
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recipient
population
under
fee
for
service.
1
c.
Enhance
monitoring
of
the
reduction
in
or
suspension
2
or
termination
of
services
provided
to
Medicaid
recipients,
3
including
reductions
in
the
provision
of
home
and
4
community-based
services
waiver
services
or
increases
in
home
5
and
community-based
services
waiver
waiting
lists.
Medicaid
6
managed
care
organizations
shall
provide
data
to
the
department
7
as
necessary
for
the
department
to
compile
periodic
reports
on
8
the
numbers
of
individuals
transferred
from
state
institutions
9
and
long-term
care
facilities
to
home
and
community-based
10
services,
and
the
associated
savings.
Any
savings
resulting
11
from
the
transfers
as
certified
by
the
department
shall
be
12
deposited
in
the
Medicaid
reinvestment
fund
created
in
section
13
249A.4C.
14
d.
(1)
Require
each
Medicaid
managed
care
organization
to
15
adhere
to
reasonableness
and
service
authorization
standards
16
that
are
appropriate
for
and
do
not
disadvantage
those
17
individuals
who
have
ongoing
chronic
conditions
or
who
require
18
long-term
services
and
supports.
Services
and
supports
for
19
individuals
with
ongoing
chronic
conditions
or
who
require
20
long-term
services
and
supports
shall
be
authorized
in
a
manner
21
that
reflects
the
recipient’s
continuing
need
for
such
services
22
and
supports,
and
limits
shall
be
consistent
with
a
recipient’s
23
current
needs
assessment
and
person-centered
service
plan.
24
(2)
In
addition
to
other
provisions
relating
to
25
community-based
case
management
continuity
of
care
26
requirements,
Medicaid
managed
care
contractors
shall
provide
27
the
option
to
the
case
manager
of
a
Medicaid
recipient
who
28
retained
the
case
manager
during
the
six
months
of
transition
29
to
Medicaid
managed
care,
if
the
recipient
chooses
to
continue
30
to
retain
that
case
manager
beyond
the
six-month
transition
31
period
and
if
the
case
manager
is
not
otherwise
a
participating
32
provider
of
the
recipient’s
managed
care
organization
provider
33
network,
to
enter
into
a
single
case
agreement
to
continue
to
34
provide
case
management
services
to
the
Medicaid
recipient.
35
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e.
Ensure
that
Medicaid
recipients
are
provided
care
1
coordination
and
case
management
by
appropriately
trained
2
professionals
in
a
conflict-free
manner.
Care
coordination
and
3
case
management
shall
be
provided
in
a
patient-centered
and
4
family-centered
manner
that
requires
a
knowledge
of
community
5
supports,
a
reasonable
ratio
of
care
coordinators
and
case
6
managers
to
Medicaid
recipients,
standards
for
frequency
of
7
contact
with
the
Medicaid
recipient,
and
specific
and
adequate
8
reimbursement.
9
f.
A
Medicaid
managed
care
contract
shall
include
a
10
provision
for
continuity
and
coordination
of
care
for
a
11
consumer
transitioning
to
Medicaid
managed
care,
including
12
maintaining
existing
provider-recipient
relationships
and
13
honoring
the
amount,
duration,
and
scope
of
a
recipient’s
14
authorized
services
based
on
the
recipient’s
medical
history
15
and
needs.
In
the
initial
transition
to
Medicaid
managed
care,
16
to
ensure
the
least
amount
of
disruption,
Medicaid
managed
17
care
organizations
shall
provide,
at
a
minimum,
a
one-year
18
transition
of
care
period
for
all
provider
types,
regardless
19
of
network
status
with
an
individual
Medicaid
managed
care
20
organization.
21
g.
Ensure
that
a
Medicaid
managed
care
organization
does
22
not
arbitrarily
deny
coverage
for
medically
necessary
services
23
based
solely
on
financial
reasons.
24
h.
Ensure
that
dental
coverage,
if
not
integrated
into
25
an
overall
Medicaid
managed
care
contract,
is
part
of
the
26
overall
holistic,
integrated
coverage
for
physical,
behavioral,
27
and
long-term
services
and
supports
provided
to
a
Medicaid
28
recipient.
29
i.
Require
each
Medicaid
managed
care
organization
to
30
collect,
maintain,
retain,
and
share
data
as
necessary
to
31
inform
monitoring
activities
including
but
not
limited
to
32
verifying
the
offering
and
actual
utilization
of
services
and
33
supports
and
value-added
services,
an
individual
recipient’s
34
encounters
and
the
costs
associated
with
each
encounter,
and
35
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requests
and
associated
approvals
or
denials
of
services.
1
Verification
of
actual
receipt
of
services
and
supports
and
2
value-added
services
shall,
at
a
minimum,
consist
of
comparing
3
receipt
of
service
against
both
what
was
authorized
in
the
4
recipient’s
benefit
or
service
plan
and
what
was
actually
5
reimbursed.
Value-added
services
shall
not
be
reportable
as
6
allowable
medical
or
administrative
costs
or
factored
into
rate
7
setting,
and
the
costs
of
value-added
services
shall
not
be
8
passed
on
to
recipients
or
providers.
9
j.
Provide
periodic
reports
to
the
governor
and
the
general
10
assembly
regarding
changes
in
quality
of
care
and
health
11
outcomes
for
Medicaid
recipients
under
managed
care
compared
to
12
quality
of
care
and
health
outcomes
of
the
same
populations
of
13
Medicaid
recipients
prior
to
January
1,
2016.
14
k.
Require
each
Medicaid
managed
care
organization
to
15
maintain
records
of
complaints,
grievances,
and
appeals,
and
16
report
the
number
and
types
of
complaints,
grievances,
and
17
appeals
filed,
the
resolution
of
each,
and
a
description
of
18
any
patterns
or
trends
identified
to
the
department
of
human
19
services
and
the
health
policy
oversight
committee
created
20
in
section
2.45,
on
a
monthly
basis.
The
department
shall
21
review
and
compile
the
data
on
a
quarterly
basis
and
make
the
22
compilations
available
to
the
public.
Following
review
of
23
reports
submitted
by
the
department,
a
Medicaid
managed
care
24
organization
shall
take
any
corrective
action
required
by
the
25
department
and
shall
be
subject
to
any
applicable
penalties.
26
l.
Require
Medicaid
managed
care
organizations
to
survey
27
Medicaid
recipients,
to
collect
satisfaction
data
using
a
28
uniform
instrument,
and
to
provide
a
detailed
analysis
of
29
recipient
satisfaction
as
well
as
various
metrics
regarding
the
30
volume
of
and
timelines
in
responding
to
recipient
complaints
31
and
grievances
as
directed
by
the
department
of
human
services.
32
2.
CHILDREN.
33
a.
The
hawk-i
board
created
under
section
514I.5
shall
34
provide
recommendations
to
the
director
of
human
services
35
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relating
to
the
application
of
Medicaid
managed
care
to
the
1
child
population.
At
a
minimum,
the
board
shall:
2
(1)
Require
that
all
Medicaid
managed
care
organization
3
contracts
specifically
and
appropriately
address
the
unique
4
needs
of
children
and
children’s
health
care
delivery.
5
(a)
Medicaid
managed
care
organizations
shall
maintain
6
child
health
panels
that
include
representatives
of
child
7
health,
welfare,
policy,
and
advocacy
organizations
in
the
8
state
that
address
child
health
and
child
well-being.
9
(b)
Medicaid
managed
care
contracts
that
apply
to
10
children’s
health
care
delivery
shall
address
early
11
intervention
and
prevention
strategies,
the
provision
of
12
a
child
health
care
delivery
infrastructure
for
children
13
with
special
health
care
needs,
utilization
of
current
14
standards
and
guidelines
for
children’s
health
care
and
15
pediatric-specific
screening
and
assessment
tools,
the
16
inclusion
of
pediatric
specialty
providers
in
the
provider
17
network,
and
the
utilization
of
health
homes
for
children
and
18
youth
with
special
health
care
needs
including
intensive
care
19
coordination
and
family
support
and
access
to
a
professional
20
family-to-family
support
system.
Such
contracts
shall
utilize
21
pediatric-specific
quality
measures
and
assessment
tools
22
which
shall
align
with
existing
pediatric-specific
measures
23
as
determined
in
consultation
with
the
child
health
panel
and
24
approved
by
the
hawk-i
board.
25
(c)
Medicaid
managed
care
contracts
shall
provide
special
26
incentives
for
innovative
and
evidence-based
preventive,
27
behavioral,
and
developmental
health
care
and
mental
health
28
care
for
children’s
programs
that
improve
the
life
course
29
trajectory
of
those
children.
30
(d)
The
information
collected
from
the
pediatric-specific
31
assessments
shall
be
used
to
identify
health
risks
and
social
32
determinants
of
health
that
impact
health
outcomes.
Medicaid
33
managed
care
organizations
and
providers
shall
use
this
data
in
34
care
coordination
and
interventions
to
improve
patient
outcomes
35
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and
to
drive
program
designs
that
improve
the
health
of
the
1
population.
Medicaid
managed
care
organizations
shall
share
2
aggregate
assessment
data
with
providers
on
a
routine
basis.
3
(2)
Review
benefit
plans
and
utilization
review
provisions
4
and
ensure
that
benefits
provided
to
children
under
Medicaid
5
managed
care,
at
a
minimum,
reflect
those
required
by
state
law
6
as
specified
in
section
514I.5
and
are
provided
as
medically
7
necessary
relative
to
the
child
population
served
and
based
on
8
the
needs
of
the
program
recipient
and
the
program
recipient’s
9
medical
history.
10
b.
In
order
to
monitor
the
quality
of
and
access
to
health
11
care
for
children
receiving
coverage
under
the
Medicaid
12
program,
each
Medicaid
managed
care
organization
shall
13
uniformly
report,
in
a
template
format
designated
by
the
14
department
of
human
services,
the
number
of
claims
submitted
by
15
providers
and
the
percentage
of
claims
approved
by
the
Medicaid
16
managed
care
organization
for
the
early
and
periodic
screening,
17
diagnostic,
and
treatment
(EPSDT)
benefit
based
on
the
Iowa
18
EPSDT
care
for
kids
health
maintenance
recommendations,
19
including
but
not
limited
to
physical
exams,
immunizations,
the
20
seven
categories
of
developmental
and
behavioral
screenings,
21
vision
and
hearing
screenings,
and
lead
testing.
22
3.
PROVIDER
PARTICIPATION
ENHANCEMENT.
23
a.
Ensure
that
savings
achieved
through
Medicaid
managed
24
care
does
not
come
at
the
expense
of
further
reductions
in
25
provider
rates.
The
department
shall
ensure
that
Medicaid
26
managed
care
organizations
use
reasonable
reimbursement
27
standards
for
all
provider
types
and
compensate
providers
for
28
covered
services
at
not
less
than
the
minimum
reimbursement
29
established
by
state
law
applicable
to
fee
for
service
for
a
30
respective
provider,
service,
or
product
for
a
fiscal
year
31
and
as
determined
in
conjunction
with
actuarially
sound
rate
32
setting
procedures.
Such
reimbursement
shall
extend
for
the
33
entire
duration
of
a
managed
care
contract.
34
b.
To
enhance
continuity
of
care
in
the
provision
of
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pharmacy
services,
Medicaid
managed
care
organizations
shall
1
utilize
the
same
preferred
drug
list,
recommended
drug
list,
2
prior
authorization
criteria,
and
other
utilization
management
3
strategies
that
apply
to
the
state
program
directly
under
fee
4
for
service
and
shall
apply
other
provisions
of
applicable
5
state
law
including
those
relating
to
chemically
unique
mental
6
health
prescription
drugs.
Reimbursement
rates
established
7
under
Medicaid
managed
care
contracts
for
ingredient
cost
8
reimbursement
and
dispensing
fees
shall
be
subject
to
and
shall
9
reflect
provisions
of
state
and
federal
law,
including
the
10
minimum
reimbursements
established
in
state
law
for
fee
for
11
service
for
a
fiscal
year.
12
c.
Address
rate
setting
and
reimbursement
of
the
entire
13
scope
of
services
provided
under
the
Medicaid
program
to
14
ensure
the
adequacy
of
the
provider
network
and
to
ensure
15
that
providers
that
contribute
to
the
holistic
health
of
the
16
Medicaid
recipient,
whether
inside
or
outside
of
the
provider
17
network,
are
compensated
for
their
services.
18
d.
Managed
care
contractors
shall
submit
financial
19
documentation
to
the
department
of
human
services
demonstrating
20
payment
of
claims
and
expenses
by
provider
type.
21
e.
Participating
Medicaid
providers
under
a
managed
care
22
contract
shall
be
allowed
to
submit
claims
for
up
to
365
days
23
following
discharge
of
a
Medicaid
recipient
from
a
hospital
or
24
following
the
date
of
service.
25
f.
(1)
A
managed
care
contract
entered
into
on
or
after
26
July
1,
2015,
shall,
at
a
minimum,
reflect
all
of
the
following
27
provisions
and
requirements,
and
shall
extend
the
following
28
payment
rates
based
on
the
specified
payment
floor,
as
29
applicable
to
the
provider
type:
30
(a)
In
calculating
the
rates
for
prospective
payment
system
31
hospitals,
the
following
base
rates
shall
be
used:
32
(i)
The
inpatient
diagnostic
related
group
base
rates
and
33
certified
unit
per
diem
in
effect
on
October
1,
2015.
34
(ii)
The
outpatient
ambulatory
payment
classification
base
35
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rates
in
effect
on
July
1,
2015.
1
(iii)
The
inpatient
psychiatric
certified
unit
per
diem
in
2
effect
on
October
1,
2015.
3
(iv)
The
inpatient
physical
rehabilitation
certified
unit
4
per
diem
in
effect
on
October
1,
2015.
5
(b)
In
calculating
the
critical
access
hospital
payment
6
rates,
the
following
base
rates
shall
be
used:
7
(i)
The
inpatient
diagnostic
related
group
base
rates
in
8
effect
on
July
1,
2015.
9
(ii)
The
outpatient
cost-to-charge
ratio
in
effect
on
July
10
1,
2015.
11
(iii)
The
swing
bed
per
diem
in
effect
on
July
1,
2015.
12
(c)
Critical
access
hospitals
shall
receive
cost-based
13
reimbursement
for
one
hundred
percent
of
the
reasonable
costs
14
for
the
provision
of
services
to
Medicaid
recipients.
15
(d)
Critical
access
hospitals
shall
submit
annual
cost
16
reports
and
managed
care
contractors
shall
submit
annual
17
payment
reports
to
the
department
of
human
services.
The
18
department
shall
reconcile
the
critical
access
hospital’s
19
reported
costs
with
the
managed
care
contractor’s
reported
20
payments.
The
department
shall
require
the
managed
care
21
contractor
to
retroactively
reimburse
a
critical
access
22
hospital
for
underpayments.
23
(2)
For
managed
care
contract
periods
subsequent
to
the
24
initial
contract
period,
base
rates
for
prospective
payment
25
system
hospitals
and
critical
access
hospitals
shall
be
26
calculated
using
the
base
rate
for
the
prior
contract
period
27
plus
3
percent.
Prospective
payment
system
hospital
and
28
critical
access
hospital
base
rates
shall
at
no
time
be
less
29
than
the
previous
contract
period’s
base
rates.
30
(3)
A
managed
care
contract
shall
require
out-of-network
31
prospective
payment
system
hospital
and
critical
access
32
hospital
payment
rates
to
meet
or
exceed
ninety-nine
percent
of
33
the
rates
specified
for
the
respective
in-network
hospitals
in
34
accordance
with
this
paragraph
“f”.
35
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g.
If
the
department
of
human
services
collects
ownership
1
and
control
information
from
Medicaid
providers
pursuant
to
42
2
C.F.R.
§455.104,
a
managed
care
organization
under
contract
3
with
the
state
shall
not
also
require
submission
of
this
4
information
from
approved
enrolled
Medicaid
providers.
5
h.
(1)
Ensure
that
a
Medicaid
managed
care
organization
6
develops
and
maintains
a
provider
network
of
qualified
7
providers
who
meet
state
licensing,
credentialing,
and
8
certification
requirements,
as
applicable,
which
network
shall
9
be
sufficient
to
provide
adequate
access
to
all
services
10
covered
and
for
all
populations
served
under
the
managed
11
care
contract.
Medicaid
managed
care
organizations
shall
12
incorporate
existing
and
traditional
providers,
including
13
but
not
limited
to
those
providers
that
comprise
the
Iowa
14
collaborative
safety
net
provider
network
created
in
section
15
135.153,
into
their
provider
networks.
16
(2)
Ensure
that
respective
Medicaid
populations
are
17
managed
at
all
times
within
funding
limitations
and
contract
18
terms.
The
department
shall
also
monitor
service
delivery
19
and
utilization
to
ensure
the
responsibility
for
provision
20
of
services
to
Medicaid
recipients
is
not
shifted
to
21
non-Medicaid
covered
services
to
attain
savings,
and
that
such
22
responsibility
is
not
shifted
to
mental
health
and
disability
23
services
regions,
local
public
health
agencies,
aging
and
24
disability
resource
centers,
or
other
entities
unless
agreement
25
to
provide,
and
provision
for
adequate
compensation
for,
such
26
services
is
agreed
to
between
the
affected
entities
in
advance.
27
i.
Medicaid
managed
care
organizations
shall
provide
an
28
enrolled
Medicaid
provider
approved
by
the
department
of
29
human
services
the
opportunity
to
be
a
participating
network
30
provider.
31
j.
Medicaid
managed
care
organizations
shall
include
32
provider
appeals
and
grievance
procedures
that
in
part
allow
33
a
provider
to
file
a
grievance
independently
but
on
behalf
34
of
a
Medicaid
recipient
and
to
appeal
claims
denials
which,
35
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if
determined
to
be
based
on
claims
for
medically
necessary
1
services
whether
or
not
denied
on
an
administrative
basis,
2
shall
receive
appropriate
payment.
3
4.
CAPITATION
RATES
AND
MEDICAL
LOSS
RATIO.
4
a.
Capitation
rates
shall
be
developed
based
on
all
5
reasonable,
appropriate,
and
attainable
costs.
Costs
that
are
6
not
reasonable,
appropriate,
or
attainable,
including
but
not
7
limited
to
improper
payment
recoveries,
shall
not
be
included
8
in
the
development
of
capitated
rates.
9
b.
Capitation
rates
for
Medicaid
recipients
falling
within
10
different
rate
cells
shall
not
be
expected
to
cross-subsidize
11
one
another
and
the
data
used
to
set
capitation
rates
shall
12
be
relevant
and
timely
and
tied
to
the
appropriate
Medicaid
13
population.
14
c.
Any
increase
in
capitation
rates
for
managed
care
15
contractors
is
subject
to
prior
statutory
approval
and
shall
16
not
exceed
three
percent
over
the
existing
capitation
rate
17
in
any
one-year
period
or
five
percent
over
the
existing
18
capitation
rate
in
any
two-year
period.
19
d.
A
managed
care
contract
shall
impose
a
minimum
Medicaid
20
loss
ratio
of
at
least
eighty-eight
percent.
In
calculating
21
the
medical
loss
ratio,
medical
costs
or
benefit
expenses
shall
22
include
only
those
costs
directly
related
to
patient
medical
23
care
and
not
ancillary
expenses,
including
but
not
limited
to
24
any
of
the
following:
25
(1)
Program
integrity
activities.
26
(2)
Utilization
review
activities.
27
(3)
Fraud
prevention
activities
beyond
the
scope
of
those
28
activities
necessary
to
recover
incurred
claims.
29
(4)
Provider
network
development,
education,
or
management
30
activities.
31
(5)
Provider
credentialing
activities.
32
(6)
Marketing
expenses.
33
(7)
Administrative
costs
associated
with
recipient
34
incentives.
35
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(8)
Clinical
data
collection
activities.
1
(9)
Claims
adjudication
expenses.
2
(10)
Customer
service
or
health
care
professional
hotline
3
services
addressing
nonclinical
recipient
questions.
4
(11)
Value-added
or
cost-containment
services,
wellness
5
programs,
disease
management,
and
case
management
or
care
6
coordination
programs.
7
(12)
Health
quality
improvement
activities
unless
8
specifically
approved
as
a
medical
cost
by
state
law.
Costs
of
9
health
quality
improvement
activities
included
in
determining
10
the
medical
loss
ratio
shall
be
only
those
activities
that
are
11
independent
improvements
measurable
in
individual
patients.
12
(13)
Insurer
claims
review
activities.
13
(14)
Information
technology
costs
unless
they
directly
14
and
credibly
improve
the
quality
of
health
care
and
do
not
15
duplicate,
conflict
with,
or
fail
to
be
compatible
with
similar
16
health
information
technology
efforts
of
providers.
17
(15)
Legal
department
costs
including
information
18
technology
costs,
expenses
incurred
for
review
and
denial
of
19
claims,
legal
costs
related
to
defending
claims,
settlements
20
for
wrongly
denied
claims,
and
costs
related
to
administrative
21
claims
handling
including
salaries
of
administrative
personnel
22
and
legal
costs.
23
(16)
Taxes
unrelated
to
premiums
or
the
provision
of
medical
24
care.
Only
state
and
federal
taxes
and
licensing
or
regulatory
25
fees
relevant
to
actual
premiums
collected,
not
including
such
26
taxes
and
fees
as
property
taxes,
taxes
on
investment
income,
27
taxes
on
investment
property,
and
capital
gains
taxes,
may
be
28
included
in
determining
the
medical
loss
ratio.
29
e.
(1)
Provide
enhanced
guidance
and
criteria
for
defining
30
medical
and
administrative
costs,
recoveries,
and
rebates
31
including
pharmacy
rebates,
and
the
recording,
reporting,
and
32
recoupment
of
such
costs,
recoveries,
and
rebates
realized.
33
(2)
Medicaid
managed
care
organizations
shall
offset
34
recoveries,
rebates,
and
refunds
against
medical
costs,
include
35
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only
allowable
administrative
expenses
in
the
determination
of
1
administrative
costs,
report
costs
related
to
subcontractors
2
properly,
and
have
complete
systems
checks
and
review
processes
3
to
identify
overpayment
possibilities.
4
(3)
Medicaid
managed
care
contractors
shall
submit
publicly
5
available,
comprehensive
financial
statements
to
verify
that
6
the
minimum
medical
loss
ratio
is
being
met
and
shall
be
7
subject
to
periodic
audits.
8
5.
DATA
AND
INFORMATION,
EVALUATION,
AND
OVERSIGHT.
9
a.
Develop
and
administer
a
clear,
detailed
policy
10
regarding
the
collection,
storage,
integration,
analysis,
11
maintenance,
retention,
reporting,
sharing,
and
submission
12
of
data
and
information
from
the
Medicaid
managed
care
13
organizations
and
shall
require
each
Medicaid
managed
care
14
organization
to
have
in
place
a
data
and
information
system
to
15
ensure
that
accurate
and
meaningful
data
is
available.
At
a
16
minimum,
the
data
shall
allow
the
department
to
effectively
17
measure
and
monitor
Medicaid
managed
care
organization
18
performance,
quality,
outcomes
including
recipient
health
19
outcomes,
service
utilization,
finances,
program
integrity,
20
the
appropriateness
of
payments,
and
overall
compliance
with
21
contract
requirements;
perform
risk
adjustments
and
determine
22
actuarially
sound
capitation
rates
and
appropriate
provider
23
reimbursements;
verify
that
the
minimum
medical
loss
ratio
is
24
being
met;
ensure
recipient
access
to
and
use
of
services;
25
create
quality
measures;
and
provide
for
program
transparency.
26
b.
Medicaid
managed
care
organizations
shall
directly
27
capture
and
retain
and
shall
report
actual
and
detailed
28
medical
claims
costs
and
administrative
cost
data
to
the
29
department
as
specified
by
the
department.
Medicaid
managed
30
care
organizations
shall
allow
the
department
to
thoroughly
and
31
accurately
monitor
the
medical
claims
costs
and
administrative
32
costs
data
Medicaid
managed
care
organizations
report
to
the
33
department.
34
c.
Conduct
regular
audits
of
Medicaid
managed
care
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contracts
according
to
a
routine,
ongoing
schedule
to
ensure
1
compliance
including
with
respect
to
appropriate
medical
costs,
2
allowable
administrative
costs,
the
medical
loss
ratio,
cost
3
recoveries,
rebates,
overpayments,
and
compliance
with
specific
4
contract
performance
requirements.
5
d.
Following
completion
of
the
initial
year
of
6
implementation
of
Medicaid
managed
care,
the
department
shall
7
hire
an
independent
performance
auditor
to
perform
an
audit
of
8
the
Medicaid
managed
care
program
and
participating
Medicaid
9
managed
care
organizations
to
determine
if
the
state
has
10
sufficient
infrastructure
and
controls
in
place
to
effectively
11
oversee
the
Medicaid
managed
care
organizations
and
the
12
Medicaid
program
to
ensure,
at
a
minimum,
compliance
with
13
Medicaid
managed
care
organization
contracts
and
to
prevent
14
fraud,
abuse,
and
overpayments.
The
results
of
the
audit
shall
15
be
submitted
to
the
governor,
the
general
assembly,
and
the
16
health
policy
oversight
committee
created
in
section
2.45.
17
e.
Publish
benchmark
indicators
based
on
Medicaid
program
18
outcomes
from
the
fiscal
year
beginning
July
1,
2015,
to
19
be
used
to
compare
outcomes
of
the
Medicaid
program
as
20
administered
by
the
state
program
prior
to
July
1,
2015,
to
21
those
outcomes
of
the
program
under
Medicaid
managed
care.
The
22
outcomes
shall
include
a
comparison
of
actual
costs
of
the
23
program
as
administered
prior
to
and
after
implementation
of
24
Medicaid
managed
care.
25
f.
Review
and
approve
or
deny
approval
of
contract
26
amendments
on
an
ongoing
basis
to
provide
for
continuous
27
improvement
in
Medicaid
managed
care
and
to
incorporate
any
28
changes
based
on
changes
in
law
or
policy.
29
g.
(1)
Require
managed
care
contractors
to
track
and
report
30
on
a
monthly
basis
to
the
department
of
human
services,
all
of
31
the
following:
32
(a)
The
number
and
details
relating
to
prior
authorization
33
requests
and
denials.
34
(b)
The
ten
most
common
reasons
for
claims
denials.
35
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Information
reported
by
a
managed
care
contractor
relative
1
to
claims
shall
also
include
the
number
of
claims
denied,
2
appealed,
and
overturned
based
on
provider
type
and
service
3
type.
4
(c)
Utilization
of
health
care
services
by
diagnostic
5
related
group
and
ambulatory
payment
classification
as
well
as
6
total
claims
volume.
7
(2)
The
department
shall
make
the
monthly
reports
available
8
to
the
public.
9
h.
Medicaid
managed
care
organizations
shall
maintain
10
stakeholder
panels
comprised
of
an
equal
number
of
Medicaid
11
recipients
and
providers.
Medicaid
managed
care
organizations
12
shall
provide
for
separate
provider-specific
panels
to
address
13
detailed
payment,
claims,
process,
and
other
issues
as
well
as
14
grievance
and
appeals
processes.
15
i.
Medicaid
managed
care
contracts
shall
align
economic
16
incentives,
delivery
system
reforms,
and
performance
and
17
outcome
metrics
with
those
of
the
state
innovation
models
18
initiatives
and
Medicaid
accountable
care
organizations.
19
The
department
of
human
services
shall
develop
and
utilize
20
a
common,
uniform
set
of
process,
quality,
and
consumer
21
satisfaction
measures
across
all
Medicaid
payors
and
providers
22
that
align
with
those
developed
through
the
state
innovation
23
models
initiative
and
shall
ensure
that
such
measures
are
24
expanded
and
adjusted
to
address
additional
populations
and
25
to
meet
population
health
objectives.
Medicaid
managed
care
26
contracts
shall
include
long-term
performance
and
outcomes
27
goals
that
reward
success
in
achieving
population
health
goals
28
such
as
improved
community
health
metrics.
29
j.
Require
consistency
and
uniformity
of
processes,
30
procedures,
and
forms
across
all
Medicaid
managed
care
31
organizations
to
reduce
the
administrative
burden
to
providers
32
and
consumers
and
to
increase
efficiencies
in
the
program.
33
Such
requirements
shall
apply
to
but
are
not
limited
to
34
areas
of
uniform
cost
and
quality
reporting,
uniform
prior
35
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authorization
requirements
and
procedures,
centralized,
1
uniform,
and
seamless
credentialing
requirements
and
2
procedures,
and
uniform
critical
incident
reporting.
3
k.
Medicaid
managed
care
organizations
and
any
entity
with
4
which
a
managed
care
organization
contracts
for
the
performance
5
of
services
shall
disclose
at
no
cost
to
the
department
all
6
discounts,
incentives,
rebates,
fees,
free
goods,
bundling
7
arrangements,
and
other
agreements
affecting
the
net
cost
of
8
goods
or
services
provided
under
a
managed
care
contract.
9
Sec.
16.
RETROACTIVE
APPLICABILITY.
The
section
of
this
Act
10
relating
to
directives
for
Medicaid
program
policy
improvements
11
applies
retroactively
to
July
1,
2015.
12
Sec.
17.
EFFECTIVE
UPON
ENACTMENT.
This
Act,
being
deemed
13
of
immediate
importance,
takes
effect
upon
enactment.
14
EXPLANATION
15
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
16
the
explanation’s
substance
by
the
members
of
the
general
assembly.
17
This
bill
relates
to
Medicaid
program
improvement.
18
The
bill
provides
legislative
findings,
goals,
and
the
19
intent
for
the
program.
20
The
bill
provides
for
a
review
of
program
integrity
21
activities
by
a
workgroup,
required
to
make
recommendations
22
to
the
governor
and
general
assembly
by
November
15,
2016,
to
23
provide
findings
and
recommendations
for
a
coordinated
approach
24
to
provide
for
comprehensive
and
effective
administration
of
25
program
integrity
activities
to
support
such
a
system.
26
The
bill
creates
a
Medicaid
reinvestment
fund
for
the
27
deposit
of
savings
related
to
and
realized
from
Medicaid
28
managed
care.
Moneys
in
the
fund
are
subject
to
appropriation
29
by
the
general
assembly
for
the
Medicaid
program.
30
The
bill
provides
additional
duties
for
and
authority
to
31
the
office
of
long-term
care
ombudsman
relating
to
providing
32
advocacy
services
and
assistance
for
Medicaid
recipients
who
33
receive
long-term
services
and
supports.
34
The
bill
clarifies
the
membership
of
the
medical
assistance
35
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2213
advisory
council
and
the
executive
committee,
provides
for
1
the
creation
of
subcommittees
of
the
council
relating
to
2
stakeholder
safeguards;
long-term
services
and
supports;
3
transparency,
data,
and
program
evaluation;
and
program
4
integrity.
5
The
bill
directs
the
patient-centered
health
advisory
6
council
to
assess
the
health
resources
and
infrastructure
7
of
the
state
to
recommend
more
appropriate
alignment
with
8
changes
in
health
care
delivery
and
the
integrated,
holistic,
9
population
health-based
approach
to
health
and
health
care.
10
The
bill
directs
the
council
to
perform
an
initial
review
and
11
submit
a
report
by
January
1,
2017,
to
the
governor
and
the
12
general
assembly,
and
to
submit
subsequent
reports
on
January
13
1,
annually,
thereafter.
14
The
bill
directs
the
department
of
human
services
and
other
15
appropriate
entities
to
undertake
specific
tasks
relating
to
16
Medicaid
program
policy
improvement
in
the
areas
of
consumer
17
protections,
children,
provider
participation
enhancement,
18
capitation
rates
and
medical
loss
ratio,
and
data
and
19
information,
evaluation,
and
oversight.
20
The
section
of
the
bill
relating
to
directives
for
Medicaid
21
program
policy
improvements
is
retroactively
applicable
to
July
22
1,
2015.
23
The
bill
takes
effect
upon
enactment.
24
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