HF 2009 (LSB 5035YH (5) 88)

HOUSE FILE 2009

BY  BRECKENRIDGE

A BILL FOR

An Act relating to reimbursement for services provided in an emergency department to Medicaid members.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  MEDICAID —— REIMBURSEMENT FOR EMERGENCY DEPARTMENT SERVICES.
   1.  Reimbursement provided under both Medicaid fee-for-service and managed care administration for services delivered in an emergency department shall comply with all of the following:
   a.  Reimbursement shall be based on the services provided as indicated by the patient’s presenting symptoms and not solely on the patient’s eventual or final diagnosis.
   b.  Reimbursement shall reflect the prudent layperson standard relative to the definition of an emergency medical condition pursuant to 24 C.F.R. §2590.715-2719A(b)(4)(i).
   c.  Reimbursement shall not be denied, including retroactively denied, restricted, or down-coded based on a policy of selective emergency services coverage. For the purposes of this subsection, “policy of selective emergency services coverage” means any practice making reimbursement for emergency services dependent upon a determination of whether an injury, symptom, complaint, or other presenting condition strictly constitutes an emergency medical condition.
   2.  The department of human services shall adopt rules pursuant to chapter 17A to administer this section. Any contract the department enters into with a managed care organization shall require the managed care organization to comply with this section and the rules adopted under this section.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to reimbursement of services delivered in an emergency department under the Medicaid program. The bill requires that reimbursement provided under both Medicaid fee-for-service and managed care administration for services delivered in an emergency department shall comply with all of the following:
   1. Be based on the services provided as indicated by the patient’s presenting symptoms and not on the patient’s eventual or final diagnosis.
   2. Reflect the prudent layperson standard relative to the definition of an emergency medical condition under federal law which provides that an emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of an individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.
   3. Shall not be denied including retroactively denied, restricted, reduced, or down-coded based on a “policy of selective emergency services coverage” which means any practice of making reimbursement for emergency services dependent upon a determination of whether an injury, symptom, complaint, or other presenting condition strictly constitutes an emergency medical condition.
   The bill requires the department of human services to adopt administrative rules and provides that any contract the department enters into with a managed care organization shall require the managed care organization to comply with the bill and the rules adopted under the bill.