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 TLSB 5711SV (2) 86 pf/nh

S.F. 2213 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 35 -1- LSB 5711SV (2) 86 pf/nh 1/ 30

S.F. 2213 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 -2- LSB 5711SV (2) 86 pf/nh 2/ 30

S.F. 2213 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 -3- LSB 5711SV (2) 86 pf/nh 3/ 30

S.F. 2213 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 35 -4- LSB 5711SV (2) 86 pf/nh 4/ 30

S.F. 2213 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 35 -5- LSB 5711SV (2) 86 pf/nh 5/ 30

S.F. 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 35 -6- LSB 5711SV (2) 86 pf/nh 6/ 30

S.F. 2213 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 35 -7- LSB 5711SV (2) 86 pf/nh 7/ 30

S.F. 2213 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 -8- LSB 5711SV (2) 86 pf/nh 8/ 30

S.F. 2213 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 -9- LSB 5711SV (2) 86 pf/nh 9/ 30

S.F. 2213 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 -10- LSB 5711SV (2) 86 pf/nh 10/ 30

S.F. 2213 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 -11- LSB 5711SV (2) 86 pf/nh 11/ 30

S.F. 2213 (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 -12- LSB 5711SV (2) 86 pf/nh 12/ 30

S.F. 2213 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. 35 -13- LSB 5711SV (2) 86 pf/nh 13/ 30

S.F. 2213 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 -14- LSB 5711SV (2) 86 pf/nh 14/ 30

S.F. 2213 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 -15- LSB 5711SV (2) 86 pf/nh 15/ 30

S.F. 2213 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 -16- LSB 5711SV (2) 86 pf/nh 16/ 30

S.F. 2213 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 -17- LSB 5711SV (2) 86 pf/nh 17/ 30

S.F. 2213 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 -18- LSB 5711SV (2) 86 pf/nh 18/ 30

S.F. 2213 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 -19- LSB 5711SV (2) 86 pf/nh 19/ 30

S.F. 2213 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 35 -20- LSB 5711SV (2) 86 pf/nh 20/ 30