S.F. _____ H.F. _____ DIVISION I 1 HEALTHY AND WELL KIDS IN IOWA —— DIRECTOR DUTIES 2 Section 1. Section 514I.4, subsection 5, Code 2018, is 3 amended by adding the following new paragraphs: 4 NEW PARAGRAPH . d. Collect and track monthly family premiums 5 to assure that payments are current. 6 NEW PARAGRAPH . e. Verify the number of program enrollees 7 with each participating insurer for determination of the amount 8 of premiums to be paid to each participating insurer. 9 Sec. 2. Section 514I.7, subsection 2, paragraphs g and i, 10 Code 2018, are amended by striking the paragraphs. 11 DIVISION II 12 SHARING OF INCARCERATION DATA 13 Sec. 3. Section 249A.38, Code 2018, is amended to read as 14 follows: 15 249A.38 Inmates of public institutions —— suspension or 16 termination of medical assistance. 17 1. The following conditions shall apply to department shall 18 suspend the eligibility of an individual who is an inmate of 19 a public institution as defined in 42 C.F.R. §435.1010 , who 20 is enrolled in the medical assistance program at the time 21 of commitment to the public institution, and who remains 22 eligible for medical assistance as an individual except for the 23 individual’s institutional status : 24 a. The department shall suspend the individual’s 25 eligibility for up to the initial twelve months of the period 26 of commitment. The department shall delay the suspension 27 of eligibility for a period of up to the first thirty days 28 of commitment if such delay is approved by the centers for 29 Medicare and Medicaid services of the United States department 30 of health and human services. If such delay is not approved, 31 the department shall suspend eligibility during the entirety 32 of the initial twelve months of the period of commitment. 33 Claims submitted on behalf of the individual under the medical 34 assistance program for covered services provided during the 35 -1- LSB 5317XD (10) 87 pf/rh 1/ 13

S.F. _____ H.F. _____ delay period shall only be reimbursed if federal financial 1 participation is applicable to such claims. 2 b. The department shall terminate an individual’s 3 eligibility following a twelve-month period of suspension 4 of the individual’s eligibility under paragraph “a” , during 5 the period of the individual’s commitment to the public 6 institution . 7 2. a. A public institution shall provide the department and 8 the social security administration with a monthly report of the 9 individuals who are committed to the public institution and of 10 the individuals who are discharged from the public institution. 11 The monthly report to the department shall include the date 12 of commitment or the date of discharge, as applicable, of 13 each individual committed to or discharged from the public 14 institution during the reporting period. The monthly report 15 shall be made through the reporting system created by the 16 department for public, nonmedical institutions to report inmate 17 populations. Any medical assistance expenditures, including 18 but not limited to monthly managed care capitation payments, 19 provided on behalf of an individual who is an inmate of a 20 public institution but is not reported to the department 21 in accordance with this subsection, shall be the financial 22 responsibility of the respective public institution. 23 b. The department shall provide a public institution with 24 the forms necessary to be used by the individual in expediting 25 restoration of the individual’s medical assistance benefits 26 upon discharge from the public institution. 27 3. This section applies to individuals as specified in 28 subsection 1 on or after January 1, 2012. 29 4. 3. The department may adopt rules pursuant to chapter 30 17A to implement this section. 31 DIVISION III 32 REPORTS —— MEDICAL ASSISTANCE DRUG UTILIZATION REVIEW AND 33 MEDICAID MANAGED CARE OVERSIGHT 34 Sec. 4. Section 249A.24, subsection 4, Code 2018, is amended 35 -2- LSB 5317XD (10) 87 pf/rh 2/ 13

S.F. _____ H.F. _____ by striking the subsection. 1 Sec. 5. 2016 Iowa Acts, chapter 1139, section 93, is amended 2 to read as follows: 3 SEC. 93. DEPARTMENT OF HUMAN SERVICES —— REPORTS. The 4 department of human services shall submit to the chairpersons 5 and ranking members of the human resources committees of the 6 senate and the house of representatives and to the chairpersons 7 and ranking members of the joint appropriations subcommittee 8 on health and human services , quarterly reports, and an 9 annual report beginning December 15, 2016, and annually by 10 December 15, thereafter 31 , regarding Medicaid program consumer 11 protections, outcome achievement, and program integrity as 12 specified in this division. The reports shall be based on and 13 updated to include the most recent information available. The 14 reports shall include an executive summary of the information 15 and data compiled, an analysis of the information and data, 16 and any trends or issues identified through such analysis, 17 to the extent such information is not otherwise considered 18 confidential or protected information pursuant to federal or 19 state law. The joint appropriations subcommittee on health and 20 human services shall dedicate a meeting of the subcommittee 21 during the subsequent session of the general assembly to review 22 the annual report. 23 1. CONSUMER PROTECTION. 24 The general assembly recognizes the need for ongoing review 25 of Medicaid member engagement with and feedback regarding 26 Medicaid managed care. The Iowa high quality health care 27 initiative shall ensure access to medically necessary services 28 and shall ensure that Medicaid members are fully engaged in 29 their own health care in order to achieve overall positive 30 health outcomes. The consumer protection component of the 31 reports submitted as required under this section shall be based 32 on all of the following reports relating to member and provider 33 services: 34 a. Member enrollment and disenrollment. 35 -3- LSB 5317XD (10) 87 pf/rh 3/ 13

S.F. _____ H.F. _____ b. Member grievances and appeals including all of the 1 following: 2 (1) The percentage of grievances and appeals resolved 3 adjudicated timely. 4 (2) The number of grievances and appeals received. 5 c. Member call center performance including the service 6 level for members, providers, and pharmacy. 7 d. Prior authorization denials and modifications including 8 all of the following: 9 (1) The percentage of prior authorizations approved, 10 denied, and modified. 11 (2) The percentage of prior authorizations processed within 12 required timeframes. 13 e. Provider network access including key gaps in provider 14 coverage based on contract time , and distance standards , and 15 market share . 16 f. Care coordination and case management, including the 17 ratio of members to care coordinators or case managers , and 18 the average number of contacts made with members per reporting 19 period . 20 g. Level of care and functional assessments, including the 21 percentage of level of care assessments completed timely. 22 h. Population-specific reporting including all of the 23 following: 24 (1) General population, including adults and children. 25 (2) Special needs, including adults and children. 26 (3) Behavioral health, including adults and children. 27 (4) Elderly. 28 i. (1) Number of individuals served on the home and 29 community-based services (HCBS) waivers by waiver type, and 30 HCBS waiver waiting list reductions or increases. 31 (2) Number of individuals enrolled in 1915(i) HCBS 32 habilitation services. 33 2. OUTCOME ACHIEVEMENT. 34 The primary focus of the general assembly in moving to 35 -4- LSB 5317XD (10) 87 pf/rh 4/ 13

S.F. _____ H.F. _____ Medicaid managed care is to improve the quality of care and 1 outcomes for Medicaid members. The state has demonstrated 2 how preventive services and the coordination of care for all 3 of a Medicaid member’s treatment significantly improve the 4 health and well-being of the state’s most vulnerable citizens. 5 In order to ensure continued improvement, ongoing review of 6 member outcomes as well as of the process that supports a 7 strong provider network is necessary. The outcome achievement 8 component of the reports submitted as required under this 9 section shall be based on all of the following reports: 10 a. Contract management including all of the following: 11 (1) Claims processing including all of the following: 12 (a) The percentage of claims paid, denied, and disputed, and 13 the ten most common reasons for claims denials. 14 (b) The percentage of claims adjudicated timely. 15 (2) Encounter data including all of the following: 16 (a) Timeliness. 17 (b) Completeness. 18 (c) Accuracy. 19 (3) Value-based purchasing (VBP) enrollment including the 20 percentage of members covered by a VBP arrangement. 21 (4) Financial information including all of the following: 22 (a) Managed care organization capitation payments. 23 (b) The medical loss ratio, administrative loss ratio, and 24 underwriting ratio. 25 (c) Program cost savings. 26 (5) Utilization of health care services by diagnostic 27 related group and ambulatory payment classification as well as 28 total claims volume. 29 (6) Utilization of value-added services. 30 (7) Payment of claims by department-identified provider 31 service type. 32 (8) Utilization of 1915(b)(3) services that are being 33 provided in lieu of state plan services, including institutions 34 for mental disease services. 35 -5- LSB 5317XD (10) 87 pf/rh 5/ 13

S.F. _____ H.F. _____ b. Member health outcomes including all of the following: 1 (1) Annual health care effectiveness and information set 2 (HEDIS) performance. 3 (2) Other quality measures including all of the following: 4 (a) Behavioral health. 5 (b) Children’s health outcomes. 6 (c) Prenatal and birth outcomes. 7 (d) Chronic condition management. 8 (e) Adult preventative care. 9 (3) Value index score (VIS) performance. 10 (4) Annual consumer assessment of health care providers and 11 systems (CAHPS) performance. 12 (5) Utilization Annual utilization information including 13 all of the following: 14 (a) Inpatient hospital admissions and potential 15 preventative admissions. 16 (b) Readmissions. 17 (c) Outpatient visits. 18 (d) Emergency department visits and potentially preventable 19 emergency department visits. 20 c. Consumer Annual consumer satisfaction survey results . 21 3. PROGRAM INTEGRITY. 22 a. The Medicaid program has traditionally included 23 comprehensive oversight and program integrity controls. 24 Under Medicaid managed care, federal, state, and contractual 25 safeguards will continue to be incorporated to prevent, detect, 26 and eliminate provider fraud, waste, and abuse to maintain a 27 sustainable Medicaid program. The program integrity component 28 of the reports submitted as required under this section shall 29 be based on all of the following reports relating to program 30 integrity: 31 (1) The include the reporting of the level of fraud, waste, 32 and abuse identified by the managed care organizations. 33 (2) Managed care organization adherence to the program 34 integrity plan, including identification of program 35 -6- LSB 5317XD (10) 87 pf/rh 6/ 13

S.F. _____ H.F. _____ overpayments. 1 (3) Notification of the state by the managed care 2 organizations regarding fraud, waste, and abuse. 3 (4) The impact of program activities on capitation 4 payments. 5 (5) Enrollment and payment information including all of the 6 following: 7 (a) Eligibility. 8 (b) Third-party liability. 9 (6) Managed care organization reserves compared to minimum 10 reserves required by the insurance division of the department 11 of commerce. 12 (7) A summary report by the insurance division of the 13 department of commerce including information relating to health 14 maintenance organization licensure, the annual independent 15 audit, insurance division reporting, and reinsurance. 16 b. The results of any external quality review organization 17 review annual technical report shall be submitted directly 18 to the governor, the general assembly, and the health policy 19 oversight committee created in section 2.45 posted publicly to 20 the department’s website . 21 c. The department of human services shall require each 22 Medicaid managed care organization to authorize the national 23 committee for quality assurance (NCQA) to submit directly to 24 the governor, the general assembly, and the health policy 25 oversight committee created in section 2.45 , the evaluation 26 report upon which the Medicaid managed care organization’s NCQA 27 accreditation was granted, and any subsequent evaluations of 28 the Medicaid managed care organization. 29 4. INCLUSION OF INFORMATION FROM OTHER OVERSIGHT ENTITIES. 30 The council on human services, the medical assistance 31 advisory council, the hawk-i board, the mental health and 32 disability services commission, and the office of long-term 33 care ombudsman shall regularly review Medicaid managed care 34 as it relates to the entity’s respective statutory duties. 35 -7- LSB 5317XD (10) 87 pf/rh 7/ 13

S.F. _____ H.F. _____ These entities shall submit executive summaries of pertinent 1 information regarding their deliberations during the prior year 2 relating to Medicaid managed care to the department of human 3 services no later than November 15, annually, for inclusion in 4 the annual report submitted as required under this section. 5 5. PUBLIC POSTING OF INFORMATION REPORTED. 6 The department of human services shall post all of the 7 reports specified under this section, as the information 8 becomes available and to the extent such information is not 9 otherwise considered confidential or protected information 10 pursuant to federal or state law, on the Iowa health link 11 internet site. 12 Sec. 6. 2016 Iowa Acts, chapter 1139, sections 95 and 96, 13 are amended by striking the sections. 14 DIVISION IV 15 IOWA HEALTH AND WELLNESS PLAN REPORT ELIMINATION 16 Sec. 7. Section 249N.8, Code 2018, is amended to read as 17 follows: 18 249N.8 Mental health services reports. 19 The department shall submit all of the following to the 20 governor and the general assembly : 21 1. Biennially , biennially , a report of the results of 22 a review, by county and region, of mental health services 23 previously funded through taxes levied by counties pursuant to 24 section 331.424A , that are funded during the reporting period 25 under the Iowa health and wellness plan. 26 2. Annually, a report of the results of a review of the 27 outcomes and effectiveness of mental health services provided 28 under the Iowa health and wellness plan. 29 DIVISION V 30 MEDICAID PROGRAM PHARMACY COPAYMENT 31 Sec. 8. 2005 Iowa Acts, chapter 167, section 42, is amended 32 to read as follows: 33 SEC. 42. COPAYMENTS FOR PRESCRIPTION DRUGS UNDER THE 34 MEDICAL ASSISTANCE PROGRAM. The department of human services 35 -8- LSB 5317XD (10) 87 pf/rh 8/ 13

S.F. _____ H.F. _____ shall require recipients of medical assistance to pay the 1 following copayments a copayment of $1 on each prescription 2 filled for a covered prescription drug, including each refill 3 of such prescription , as follows: 4 1. A copayment of $1 on each prescription filled for each 5 covered nonpreferred generic prescription drug. 6 2. A copayment of $1 for each covered preferred brand–name 7 or generic prescription drug. 8 3. A copayment of $1 for each covered nonpreferred 9 brand–name prescription drug for which the cost to the state is 10 up to and including $25. 11 4. A copayment of $2 for each covered nonpreferred 12 brand–name prescription drug for which the cost to the state is 13 more than $25 and up to and including $50. 14 5. A copayment of $3 for each covered nonpreferred 15 brand–name prescription drug for which the cost to the state 16 is more than $50 . 17 DIVISION VI 18 MEDICAL ASSISTANCE ADVISORY COUNCIL 19 Sec. 9. Section 249A.4B, subsection 2, paragraph a, 20 subparagraph (17), Code 2018, is amended to read as follows: 21 (17) The Iowa primary care association of rural health 22 clinics . 23 Sec. 10. Section 249A.4B, subsection 2, paragraph a, 24 subparagraphs (27) and (28), Code 2018, are amended by striking 25 the subparagraphs. 26 Sec. 11. Section 249A.4B, subsection 4, paragraph c, Code 27 2018, is amended to read as follows: 28 c. Based upon the deliberations of the council and the 29 executive committee, the executive committee shall make 30 recommendations to the director regarding the budget, policy , 31 and administration of the medical assistance program. 32 Sec. 12. Section 249A.4B, subsection 7, Code 2018, is 33 amended to read as follows: 34 7. The director shall consider the recommendations offered 35 -9- LSB 5317XD (10) 87 pf/rh 9/ 13

S.F. _____ H.F. _____ by the council and the executive committee in the director’s 1 preparation of medical assistance budget recommendations to 2 the council on human services pursuant to section 217.3 and in 3 implementation of medical assistance program policies. 4 DIVISION VII 5 TARGETED CASE MANAGEMENT AND INPATIENT PSYCHIATRIC SERVICES 6 REIMBURSEMENT 7 Sec. 13. Section 249A.31, Code 2018, is amended to read as 8 follows: 9 249A.31 Cost-based reimbursement. 10 1. Providers of individual case management services for 11 persons with an intellectual disability, a developmental 12 disability, or chronic mental illness shall receive cost-based 13 reimbursement for one hundred percent of the reasonable 14 costs for the provision of the services in accordance with 15 standards adopted by the mental health and disability services 16 commission pursuant to section 225C.6 . Effective July 1, 2018, 17 targeted case management services shall be reimbursed based 18 on a statewide fee schedule amount developed by rule of the 19 department pursuant to chapter 17A. 20 2. Effective July 1, 2010 2014 , the department shall apply 21 a cost-based reimbursement methodology for reimbursement of 22 psychiatric medical institution for children providers of 23 inpatient psychiatric services for individuals under twenty-one 24 years of age shall be reimbursed as follows: 25 a. For non-state-owned providers, services shall be 26 reimbursed according to a fee schedule without reconciliation . 27 b. For state-owned providers, services shall be reimbursed 28 at one hundred percent of the actual and allowable cost of 29 providing the service. 30 EXPLANATION 31 The inclusion of this explanation does not constitute agreement with 32 the explanation’s substance by the members of the general assembly. 33 This bill relates to programs and activities under the 34 purview of the department of human services (DHS). The bill is 35 -10- LSB 5317XD (10) 87 pf/rh 10/ 13

S.F. _____ H.F. _____ organized into divisions. 1 Division I of the bill relates to the healthy and well 2 kids in Iowa (hawk-i) program by transferring two duties of 3 the administrative contractor, the capitation process and 4 member premium collection, to DHS through the Iowa Medicaid 5 enterprise. 6 Division II of the bill requires public institutions to 7 provide a monthly report of the individuals who are committed 8 to the public institution and of the individuals who are 9 discharged from the public institution to DHS and to the social 10 security administration. The report to DHS is required to 11 include the date of commitment or discharge, as applicable, 12 of each individual committed to or discharged from the public 13 institution during the reporting period, and the report is to 14 be made through the reporting system created by DHS for public, 15 nonmedical institutions to report inmate populations. Any 16 medical assistance expenditures, including but not limited to 17 monthly managed care capitation payments, provided on behalf of 18 an individual who is an inmate of a public institution but is 19 not reported as required, shall be the financial responsibility 20 of the respective public institution. 21 Division III of the bill relates to reports relating to 22 the medical assistance drug utilization review commission and 23 Medicaid managed care oversight. 24 The division eliminates the requirement that the medical 25 assistance drug utilization review commission submit an 26 annual review, including facts and findings, of the drugs 27 on the department’s prior authorization list, to DHS and to 28 the members of the general assembly’s joint appropriations 29 subcommittee on health and human services. 30 The division also amends provisions in 2016 Iowa Acts 31 relating to Medicaid managed care oversight, by eliminating 32 the requirement for quarterly reports and only requiring 33 an annual report to be submitted by December 31, regarding 34 Medicaid program consumer protections, outcome achievement, and 35 -11- LSB 5317XD (10) 87 pf/rh 11/ 13

S.F. _____ H.F. _____ program integrity. The bill also eliminates the reporting of 1 certain data elements relative to consumer protections, outcome 2 achievement, and program integrity, but adds data elements 3 relating to the number of individuals enrolled in 1915(i) 4 HCBS habilitation services and the utilization of 1915(b)(3) 5 services being provided in lieu of state plan services. 6 The division strikes the sections in the 2016 Iowa Acts 7 relating to program policy improvements and single-case 8 agreements, resulting in the elimination of program policy 9 improvements relating to the recovery of costs of services 10 furnished to a recipient while an appeal is pending, 11 authorization of a provider to appeal on a recipient’s behalf 12 if the recipient designates the provider as the recipient’s 13 representative, the specification of those professionals to be 14 included as primary care providers, the prohibition against 15 more restrictive scope of practice requirements or standards of 16 practice for primary care providers than those prescribed by 17 state law, and managed care organization single-case agreements 18 with out-of-network providers. 19 Division IV of the bill eliminates the requirement that DHS 20 submit to the governor and the general assembly, annually, 21 a report of the results of a review of the outcomes and 22 effectiveness of mental health services provided under the Iowa 23 health and wellness plan. 24 Division V of the bill eliminates the various copayments for 25 a covered prescription drug under the Medicaid program based 26 upon the prescription drug’s status, and instead provides that 27 a recipient of Medicaid is required to pay a copayment of $1 28 on each prescription filled for a covered prescription drug, 29 including each refill of such prescription. 30 Division VI of the bill relates to the medical assistance 31 advisory council (MAAC). The division amends the membership of 32 the MAAC by replacing representation by the Iowa association of 33 rural health clinics with representation by the Iowa primary 34 care association, and by eliminating representation by the Iowa 35 -12- LSB 5317XD (10) 87 pf/rh 12/ 13

S.F. _____ H.F. _____ coalition of home and community-based services for seniors 1 and the Iowa adult day services association. The division 2 also eliminates the duty of the MAAC executive council to make 3 recommendations to the director of human services regarding 4 the budget of the Medicaid program and also eliminates the 5 corresponding requirement that the director of human services 6 consider the recommendations relating to the budget in the 7 director’s preparation of Medicaid budget recommendations to 8 the council on human services. 9 Division VII of the bill amends the reimbursement provision 10 for targeted case management under the Medicaid program 11 which is currently established as cost-based reimbursement 12 for 100 percent of the reasonable costs for provision of the 13 services. Under the bill, effective July 1, 2018, targeted 14 case management will instead be reimbursed based on a statewide 15 fee schedule amount developed by rule of the department in 16 accordance with Code chapter 17A. 17 The bill also amends the reimbursement for psychiatric 18 medical institutions for children to provide that inpatient 19 psychiatric services for individuals under 21 years of age that 20 are provided by non-state-owned providers shall be reimbursed 21 according to a fee schedule without reconciliation and for 22 state-owned providers, shall be reimbursed at 100 percent of 23 the actual and allowable cost of providing the service. 24 -13- LSB 5317XD (10) 87 pf/rh 13/ 13