House
Study
Bill
680
-
Introduced
HOUSE
FILE
_____
BY
(PROPOSED
COMMITTEE
ON
APPROPRIATIONS
BILL
BY
CHAIRPERSON
GRASSLEY)
A
BILL
FOR
An
Act
relating
to
programs
and
activities
under
the
purview
of
1
the
department
of
human
services.
2
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
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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
Following
the
18
first
thirty
days
of
commitment,
the
department
shall
suspend
19
the
eligibility
of
an
individual
who
is
an
inmate
of
a
public
20
institution
as
defined
in
42
C.F.R.
§435.1010
,
who
is
enrolled
21
in
the
medical
assistance
program
at
the
time
of
commitment
to
22
the
public
institution,
and
who
remains
eligible
for
medical
23
assistance
as
an
individual
except
for
the
individual’s
24
institutional
status
:
25
a.
The
department
shall
suspend
the
individual’s
26
eligibility
for
up
to
the
initial
twelve
months
of
the
period
27
of
commitment.
The
department
shall
delay
the
suspension
28
of
eligibility
for
a
period
of
up
to
the
first
thirty
days
29
of
commitment
if
such
delay
is
approved
by
the
centers
for
30
Medicare
and
Medicaid
services
of
the
United
States
department
31
of
health
and
human
services.
If
such
delay
is
not
approved,
32
the
department
shall
suspend
eligibility
during
the
entirety
33
of
the
initial
twelve
months
of
the
period
of
commitment.
34
Claims
submitted
on
behalf
of
the
individual
under
the
medical
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assistance
program
for
covered
services
provided
during
the
1
delay
period
shall
only
be
reimbursed
if
federal
financial
2
participation
is
applicable
to
such
claims.
3
b.
The
department
shall
terminate
an
individual’s
4
eligibility
following
a
twelve-month
period
of
suspension
5
of
the
individual’s
eligibility
under
paragraph
“a”
,
during
6
the
period
of
the
individual’s
commitment
to
the
public
7
institution
.
8
2.
a.
A
public
institution
shall
provide
the
department
and
9
the
social
security
administration
with
a
monthly
report
of
the
10
individuals
who
are
committed
to
the
public
institution
and
of
11
the
individuals
who
are
discharged
from
the
public
institution.
12
The
monthly
report
to
the
department
shall
include
the
date
13
of
commitment
or
the
date
of
discharge,
as
applicable,
of
14
each
individual
committed
to
or
discharged
from
the
public
15
institution
during
the
reporting
period.
The
monthly
report
16
shall
be
made
through
the
reporting
system
created
by
the
17
department
for
public,
nonmedical
institutions
to
report
inmate
18
populations.
Any
medical
assistance
expenditures,
including
19
but
not
limited
to
monthly
managed
care
capitation
payments,
20
provided
on
behalf
of
an
individual
who
is
an
inmate
of
a
21
public
institution
but
is
not
reported
to
the
department
22
in
accordance
with
this
subsection,
shall
be
the
financial
23
responsibility
of
the
respective
public
institution.
24
b.
The
department
shall
provide
a
public
institution
with
25
the
forms
necessary
to
be
used
by
the
individual
in
expediting
26
restoration
of
the
individual’s
medical
assistance
benefits
27
upon
discharge
from
the
public
institution.
28
3.
This
section
applies
to
individuals
as
specified
in
29
subsection
1
on
or
after
January
1,
2012.
30
4.
3.
The
department
may
adopt
rules
pursuant
to
chapter
31
17A
to
implement
this
section.
32
DIVISION
III
33
MEDICAID
PROGRAM
ADMINISTRATION
34
Sec.
4.
MEDICAID
PROGRAM
ADMINISTRATION.
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1.
PROVIDER
PROCESSES
AND
PROCEDURES.
1
a.
When
all
of
the
required
documents
and
other
information
2
necessary
to
process
a
claim
have
been
received
by
a
managed
3
care
organization,
the
managed
care
organization
shall
4
either
provide
payment
to
the
claimant
within
the
timelines
5
specified
in
the
managed
care
contract
or,
if
the
managed
6
care
organization
is
denying
the
claim
in
whole
or
in
part,
7
shall
provide
notice
to
the
claimant
including
the
reasons
for
8
such
denial
consistent
with
national
industry
best
practice
9
guidelines.
10
b.
If
a
managed
care
organization
discovers
that
a
claims
11
payment
barrier
is
the
result
of
a
managed
care
organization’s
12
identified
system
configuration
error,
the
managed
care
13
organization
shall
correct
such
error
and
shall
fully
and
14
accurately
reprocess
the
claims
affected
by
the
error
within
15
ninety
days
of
such
discovery.
For
the
purposes
of
this
16
paragraph,
“configuration
error”
means
an
error
in
provider
17
data,
an
incorrect
fee
schedule,
or
an
incorrect
claims
edit.
18
c.
The
department
of
human
services
shall
provide
for
19
the
development
and
require
the
use
of
standardized
Medicaid
20
provider
enrollment
forms
to
be
used
by
the
department
and
21
uniform
Medicaid
provider
credentialing
standards
to
be
used
22
by
managed
care
organizations.
The
credentialing
process
is
23
deemed
to
begin
when
the
managed
care
organization
has
received
24
all
necessary
credentialing
materials
from
the
provider
and
is
25
deemed
to
have
ended
when
written
communication
is
mailed
or
26
faxed
to
the
provider
notifying
the
provider
of
the
managed
27
care
organization’s
decision.
28
2.
MEMBER
SERVICES
AND
PROCESSES.
29
a.
If
a
Medicaid
member
prevails
in
a
review
by
a
managed
30
care
organization
or
on
appeal
regarding
the
provision
31
of
services,
the
services
subject
to
the
review
or
appeal
32
shall
be
extended
for
a
period
of
time
determined
by
the
33
director
of
human
services.
However,
services
shall
not
be
34
extended
if
there
is
a
change
in
the
member’s
condition
that
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warrants
a
change
in
services
as
determined
by
the
member’s
1
interdisciplinary
team,
there
is
a
change
in
the
member’s
2
eligibility
status
as
determined
by
the
department
of
human
3
services,
or
the
member
voluntarily
withdraws
from
services.
4
b.
If
a
Medicaid
member
is
receiving
court-ordered
services
5
or
treatment
for
a
substance-related
disorder
pursuant
to
6
chapter
125
or
for
a
mental
illness
pursuant
to
chapter
229,
7
such
services
or
treatment
shall
be
provided
and
reimbursed
8
for
an
initial
period
of
five
days
before
a
managed
care
9
organization
may
apply
medical
necessity
criteria
to
determine
10
the
most
appropriate
services,
treatment,
or
placement
for
the
11
Medicaid
member.
12
c.
The
department
of
human
services
shall
review
and
have
13
approval
authority
for
a
Medicaid
member’s
level
of
care
14
reassessment
that
indicates
a
decrease
in
the
level
of
care.
15
A
managed
care
organization
shall
comply
with
the
findings
of
16
the
departmental
review
and
approval
of
such
level
of
care
17
reassessment.
If
a
level
of
care
reassessment
indicates
there
18
is
no
change
in
a
Medicaid
member’s
level
of
care
needs,
the
19
Medicaid
member’s
existing
level
of
care
shall
be
continued.
A
20
managed
care
organization
shall
maintain
and
make
available
to
21
the
department
of
human
services
all
documentation
relating
to
22
a
Medicaid
member’s
level
of
care
assessment.
23
d.
The
department
of
human
services
shall
maintain
and
24
update
Medicaid
member
eligibility
files
in
a
timely
manner
25
consistent
with
national
industry
best
practices.
26
3.
MEDICAID
PROGRAM
REVIEW
AND
OVERSIGHT.
27
a.
(1)
The
department
of
human
services
shall
facilitate
a
28
workgroup,
in
collaboration
with
representatives
of
the
managed
29
care
organizations
and
health
home
providers,
to
review
the
30
health
home
programs.
The
review
shall
include
all
of
the
31
following:
32
(a)
An
analysis
of
the
state
plan
amendments
applicable
to
33
health
homes.
34
(b)
An
analysis
of
the
current
health
home
system,
including
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the
rationale
for
any
recommended
changes.
1
(c)
The
development
of
a
clear
and
consistent
delivery
2
model
linked
to
program-determined
outcomes
and
data
reporting
3
requirements.
4
(d)
A
work
plan
to
be
used
in
communicating
with
5
stakeholders
regarding
the
administration
and
operation
of
the
6
health
home
programs.
7
(2)
The
department
of
human
services
shall
submit
a
report
8
of
the
workgroup’s
findings
and
recommendations
by
December
9
15,
2018,
to
the
governor
and
to
the
Eighty-eighth
General
10
Assembly,
2019
session,
for
consideration.
11
b.
The
department
of
human
services,
in
collaboration
12
with
Medicaid
providers
and
managed
care
organizations,
shall
13
initiate
a
review
process
to
determine
the
effectiveness
of
14
prior
authorizations
used
by
the
managed
care
organizations
15
with
the
goal
of
making
adjustments
based
on
relevant
16
service
costs
and
member
outcomes
data
utilizing
existing
17
industry-accepted
standards.
Prior
authorization
policies
18
shall
comply
with
existing
rules,
guidelines,
and
procedures
19
developed
by
the
centers
for
Medicare
and
Medicaid
services
of
20
the
United
States
department
of
health
and
human
services.
21
c.
The
department
of
human
services
shall
enter
into
a
22
contract
with
an
independent
auditor
to
perform
an
audit
of
23
small
dollar
claims
paid
to
or
denied
Medicaid
long-term
24
services
and
supports
providers.
The
department
may
take
any
25
action
specified
in
the
managed
care
contract
relative
to
26
any
claim
the
auditor
determines
to
be
incorrectly
paid
or
27
denied,
subject
to
appeal
by
the
managed
care
organization
28
to
the
director
of
human
services.
For
the
purposes
of
this
29
paragraph,
“small
dollar
claims”
means
those
claims
less
than
30
or
equal
to
two
thousand
five
hundred
dollars.
31
DIVISION
IV
32
MEDICAID
PROGRAM
PHARMACY
COPAYMENT
33
Sec.
5.
2005
Iowa
Acts,
chapter
167,
section
42,
is
amended
34
to
read
as
follows:
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SEC.
42.
COPAYMENTS
FOR
PRESCRIPTION
DRUGS
UNDER
THE
1
MEDICAL
ASSISTANCE
PROGRAM.
The
department
of
human
services
2
shall
require
recipients
of
medical
assistance
to
pay
the
3
following
copayments
a
copayment
of
$1
on
each
prescription
4
filled
for
a
covered
prescription
drug,
including
each
refill
5
of
such
prescription
,
as
follows:
6
1.
A
copayment
of
$1
on
each
prescription
filled
for
each
7
covered
nonpreferred
generic
prescription
drug
.
8
2.
A
copayment
of
$1
for
each
covered
preferred
brand–name
9
or
generic
prescription
drug.
10
3.
A
copayment
of
$1
for
each
covered
nonpreferred
11
brand–name
prescription
drug
for
which
the
cost
to
the
state
is
12
up
to
and
including
$25.
13
4.
A
copayment
of
$2
for
each
covered
nonpreferred
14
brand–name
prescription
drug
for
which
the
cost
to
the
state
is
15
more
than
$25
and
up
to
and
including
$50.
16
5.
A
copayment
of
$3
for
each
covered
nonpreferred
17
brand–name
prescription
drug
for
which
the
cost
to
the
state
18
is
more
than
$50.
19
DIVISION
V
20
MEDICAL
ASSISTANCE
ADVISORY
COUNCIL
21
Sec.
6.
Section
249A.4B,
subsection
2,
paragraph
a,
22
subparagraphs
(27)
and
(28),
Code
2018,
are
amended
by
striking
23
the
subparagraphs.
24
Sec.
7.
MEDICAL
ASSISTANCE
ADVISORY
COUNCIL
——
REVIEW
OF
25
MEDICAID
MANAGED
CARE
REPORT
DATA.
The
executive
committee
26
of
the
medical
assistance
advisory
council
shall
review
27
the
data
collected
and
analyzed
for
inclusion
in
periodic
28
reports
to
the
general
assembly,
including
but
not
limited
29
to
the
information
and
data
specified
in
2016
Iowa
Acts,
30
chapter
1139,
section
93,
to
determine
which
data
points
and
31
information
should
be
included
and
analyzed
to
more
accurately
32
identify
trends
and
issues
with,
and
promote
the
effective
and
33
efficient
administration
of,
Medicaid
managed
care
for
all
34
stakeholders.
At
a
minimum,
the
areas
of
focus
shall
include
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consumer
protection,
provider
network
access
and
safeguards,
1
outcome
achievement,
and
program
integrity.
The
executive
2
committee
shall
report
its
findings
and
recommendations
to
the
3
medical
assistance
advisory
council
for
review
and
comment
by
4
October
1,
2018,
and
shall
submit
a
final
report
of
findings
5
and
recommendations
to
the
governor
and
the
general
assembly
by
6
December
31,
2018.
7
DIVISION
VI
8
TARGETED
CASE
MANAGEMENT
AND
INPATIENT
PSYCHIATRIC
SERVICES
9
REIMBURSEMENT
10
Sec.
8.
Section
249A.31,
Code
2018,
is
amended
to
read
as
11
follows:
12
249A.31
Cost-based
reimbursement.
13
1.
Providers
of
individual
case
management
services
for
14
persons
with
an
intellectual
disability,
a
developmental
15
disability,
or
chronic
mental
illness
shall
receive
cost-based
16
reimbursement
for
one
hundred
percent
of
the
reasonable
17
costs
for
the
provision
of
the
services
in
accordance
with
18
standards
adopted
by
the
mental
health
and
disability
services
19
commission
pursuant
to
section
225C.6
.
Effective
July
1,
2018,
20
targeted
case
management
services
shall
be
reimbursed
based
21
on
a
statewide
fee
schedule
amount
developed
by
rule
of
the
22
department
pursuant
to
chapter
17A.
23
2.
Effective
July
1,
2010
2014
,
the
department
shall
apply
24
a
cost-based
reimbursement
methodology
for
reimbursement
of
25
psychiatric
medical
institution
for
children
providers
of
26
inpatient
psychiatric
services
for
individuals
under
twenty-one
27
years
of
age
shall
be
reimbursed
as
follows:
28
a.
For
non-state-owned
providers,
services
shall
be
29
reimbursed
according
to
a
fee
schedule
without
reconciliation
.
30
b.
For
state-owned
providers,
services
shall
be
reimbursed
31
at
one
hundred
percent
of
the
actual
and
allowable
cost
of
32
providing
the
service.
33
EXPLANATION
34
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
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the
explanation’s
substance
by
the
members
of
the
general
assembly.
1
This
bill
relates
to
programs
and
activities
under
the
2
purview
of
the
department
of
human
services
(DHS).
The
bill
is
3
organized
into
divisions.
4
Division
I
of
the
bill
relates
to
the
healthy
and
well
5
kids
in
Iowa
(hawk-i)
program
by
transferring
two
duties
of
6
the
administrative
contractor,
the
capitation
process
and
7
member
premium
collection,
to
DHS
through
the
Iowa
Medicaid
8
enterprise.
9
Division
II
of
the
bill
relates
to
suspension
of
Medicaid
10
relating
to
inmates
of
public
institutions.
The
bill
requires
11
DHS
to
suspend
eligibility
of
an
individual
following
the
first
12
30
days
of
the
individual’s
commitment
to
the
institution.
The
13
bill
also
requires
public
institutions
to
provide
a
monthly
14
report
of
the
individuals
who
are
committed
to
the
public
15
institution
and
of
the
individuals
who
are
discharged
from
16
the
public
institution
to
DHS
and
to
the
social
security
17
administration.
The
report
to
DHS
is
required
to
include
18
the
date
of
commitment
or
discharge,
as
applicable,
of
19
each
individual
committed
to
or
discharged
from
the
public
20
institution
during
the
reporting
period,
and
the
report
is
to
21
be
made
through
the
reporting
system
created
by
DHS
for
public,
22
nonmedical
institutions
to
report
inmate
populations.
Any
23
medical
assistance
expenditures,
including
but
not
limited
to
24
monthly
managed
care
capitation
payments,
provided
on
behalf
of
25
an
individual
who
is
an
inmate
of
a
public
institution
but
is
26
not
reported
as
required,
shall
be
the
financial
responsibility
27
of
the
respective
public
institution.
28
Division
III
of
the
bill
relates
to
Medicaid
relating
to
29
Medicaid
provider
processes
and
procedures,
Medicaid
member
30
services
and
processes,
and
Medicaid
program
review
and
31
oversight.
32
Division
IV
of
the
bill
eliminates
the
various
copayments
33
for
a
covered
prescription
drug
under
the
Medicaid
program
34
based
upon
the
prescription
drug’s
status,
and
instead
provides
35
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that
a
recipient
of
Medicaid
is
required
to
pay
a
copayment
of
1
$1
on
each
prescription
filled
for
a
covered
prescription
drug,
2
including
each
refill
of
such
prescription.
3
Division
V
of
the
bill
relates
to
the
medical
assistance
4
advisory
council
(MAAC).
The
bill
directs
the
executive
5
committee
of
MAAC
to
review
data
collected
and
analyzed
in
6
periodic
reports
to
the
general
assembly
to
determine
which
7
data
points
should
be
included
and
analyzed
to
more
accurately
8
identify
trends
and
issues
with,
and
promote
the
effective
and
9
efficient
administration
of,
Medicaid
managed
care
for
all
10
stakeholders.
The
executive
committee
is
required
to
report
11
its
findings
and
recommendations
to
the
MAAC
for
review
and
12
comment
by
October
1,
2018,
and
to
submit
a
final
report
to
the
13
governor
and
the
general
assembly
by
December
31,
2018.
14
Division
VI
of
the
bill
amends
the
reimbursement
provision
15
for
targeted
case
management
services
under
the
Medicaid
16
program
which
is
currently
established
as
cost-based
17
reimbursement
for
100
percent
of
the
reasonable
costs
for
18
provision
of
the
services.
Under
the
bill,
effective
July
19
1,
2018,
targeted
case
management
services
will
instead
be
20
reimbursed
based
on
a
statewide
fee
schedule
amount
developed
21
by
rule
of
the
department
in
accordance
with
Code
chapter
17A.
22
This
division
of
the
bill
also
amends
the
reimbursement
23
provision
for
psychiatric
medical
institutions
for
children
to
24
provide
that
inpatient
psychiatric
services
for
individuals
25
under
21
years
of
age
that
are
provided
by
non-state-owned
26
providers
shall
be
reimbursed
according
to
a
fee
schedule
27
without
reconciliation
and
for
state-owned
providers
shall
be
28
reimbursed
at
100
percent
of
the
actual
and
allowable
cost
of
29
providing
the
service.
30
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