H.F. 2264 Section 1. MEDICAID MANAGED CARE OVERSIGHT. 1 1. Because access to services is of critical importance 2 to the vulnerable Medicaid populations receiving long-term 3 services and supports, the network of long-term services and 4 supports providers under contract with each managed care 5 organization on January 1, 2018, shall be deemed necessary 6 to meet the requirement for network adequacy. Any willing 7 provider under contract on that date shall remain a network 8 provider as long as the network provider complies with Medicaid 9 state plan requirements for that provider. The rates in effect 10 for each such provider on January 1, 2018, shall serve as the 11 rate floor for such provider through June 30, 2019, unless the 12 rate floors are otherwise amended or scheduled to be amended 13 by law. The department of human services shall adopt rules 14 pursuant to chapter 17A and shall amend all Medicaid managed 15 care contracts as necessary to administer this subsection. 16 2. The department of human services shall adopt rules 17 pursuant to chapter 17A and shall amend all Medicaid managed 18 care contracts as necessary to provide for a process, 19 under both the Medicaid fee-for-service and managed care 20 reimbursement and services delivery methodologies, for 21 reconsideration of a Medicaid member’s supports intensity scale 22 (SIS) assessment score if a member, a member’s authorized 23 representative, or a provider acting on behalf of the member 24 disputes the accuracy or adequacy of the assessment score. 25 The reconsideration process shall provide for an expedited 26 first-level review by the applicable Medicaid managed care 27 organization, followed by an appeals process in accordance 28 with contested case proceedings pursuant to chapter 17A if the 29 member, the member’s authorized representative, or a provider 30 acting on behalf of the member is dissatisfied with the notice 31 of decision resulting from the managed care organization’s 32 review. The rules adopted and the amendment to any Medicaid 33 managed care contract shall require that the expedited 34 first-level review be completed and the notice of decision 35 -1- LSB 5854YH (4) 87 pf/rh 1/ 4

H.F. 2264 be issued by the managed care organization within 30 days of 1 receipt by the managed care organization of the request for 2 reconsideration. 3 3. The department of human services and all Medicaid managed 4 care organizations under contract with the state shall maintain 5 and update member eligibility files in a timely manner. 6 Medicaid providers who, in good faith, provide services to 7 members in accordance with service plans and reimbursement 8 agreements, shall not be denied payment for services rendered. 9 Additionally, under such circumstances, payments shall not be 10 recouped by the department or a managed care organization if, 11 subsequent to the provision of such services, the managed care 12 organization or the department determines that the member was 13 not eligible for such services and if the provider of services 14 is able to demonstrate, based on the information available to 15 the provider, that the services were authorized at the time 16 the services were rendered. The department of human services 17 shall adopt rules pursuant to chapter 17A and shall amend all 18 Medicaid managed care contracts to administer this subsection. 19 4. The department of human services shall adopt rules 20 pursuant to chapter 17A and shall amend all Medicaid managed 21 care contracts to provide that if a Medicaid member prevails in 22 a first-level review by the Medicaid managed care organization 23 or on appeal in an action regarding provision of services, the 24 services subject to the review or appeal shall be extended for 25 not less than six months following the date of the decision. 26 However, services shall not be extended if there is a change in 27 the member’s condition that warrants a change in services as 28 determined by the member’s interdisciplinary team, there is a 29 change in the member’s eligibility status as determined by the 30 department, or the member voluntarily withdraws from services. 31 EXPLANATION 32 The inclusion of this explanation does not constitute agreement with 33 the explanation’s substance by the members of the general assembly. 34 This bill relates to Medicaid managed care oversight. 35 -2- LSB 5854YH (4) 87 pf/rh 2/ 4

H.F. 2264 With regard to network adequacy, the bill requires that the 1 network of long-term services and supports providers under 2 contract with each managed care organization (MCO) on January 3 1, 2018, shall be deemed necessary to meet the requirement 4 for network adequacy, and any willing provider under contract 5 on that date shall remain a network provider as long as the 6 network provider remains in compliance with Medicaid state plan 7 requirements for that provider. Additionally, the rates in 8 effect for each such provider on January 1, 2018, shall serve 9 as the rate floor for such provider through June 30, 2019, 10 unless the rate floors are amended or scheduled to be amended 11 by law. 12 With regard to supports intensity scale (SIS) assessments, 13 the bill requires provision of a process, under both Medicaid 14 fee-for-service and managed care for reconsideration of 15 a Medicaid member’s SIS assessment score if a member, a 16 member’s authorized representative, or a provider acting on 17 behalf of the member disputes the accuracy or adequacy of the 18 assessment score. The reconsideration process must provide 19 for an expedited first-level review by the applicable MCO 20 followed by an appeals process in accordance with contested 21 case proceedings if the member, the member’s authorized 22 representative, or a provider acting on behalf of the member 23 is dissatisfied with the notice of decision resulting from 24 the MCO’s review. The expedited first-level review must be 25 completed and the notice of decision must be issued by the MCO 26 within 30 days of receipt of the request for reconsideration. 27 With regard to Medicaid member eligibility, the bill 28 requires the department of human services (DHS) and all MCOs 29 under contract with the state to maintain and update member 30 eligibility files in a timely manner. Medicaid providers 31 who, in good faith, provide services to members in accordance 32 with service plans and reimbursement agreements shall not be 33 denied payment for services rendered. Additionally, under 34 such circumstances, DHS and the MCOs are prohibited from not 35 -3- LSB 5854YH (4) 87 pf/rh 3/ 4

H.F. 2264 paying or recouping payments to such providers if, subsequent 1 to the provision of services, DHS or an MCO determines that the 2 member was not eligible for such services and if the provider 3 is able to demonstrate, based on the information available to 4 the provider, that the services were authorized at the time the 5 services were rendered. 6 With regard to member appeals regarding the provision of 7 services, the bill also requires that if a Medicaid member 8 prevails in a first-level review by the MCO or on appeal, the 9 services subject to the review or appeal must be extended for 10 not less than six months following the date of the decision. 11 However, the services are not required to be extended if there 12 is a change in the member’s condition that warrants a change 13 in services as determined by the member’s interdisciplinary 14 team, there is a change in the member’s eligibility status as 15 determined by DHS, or the member voluntarily withdraws from 16 services. 17 With regard to each requirement or provision under the 18 bill, DHS is required to adopt administrative rules and amend 19 Medicaid managed care contracts to administer the requirement 20 or provision. 21 -4- LSB 5854YH (4) 87 pf/rh 4/ 4