S.F. 156 DIVISION I 1 MEDICAID MANAGED CARE TO FEE-FOR-SERVICE TRANSITION —— 2 LONG-TERM SERVICES AND SUPPORTS 3 Section 1. TERMINATION OF MEDICAID MANAGED CARE CONTRACTS 4 RELATIVE TO LONG-TERM SERVICES AND SUPPORTS POPULATION —— 5 TRANSITION TO FEE-FOR-SERVICE. The department of human 6 services shall, upon the effective date of this division 7 of this Act, provide written notice in accordance with the 8 termination provisions of the contract, to each managed care 9 organization with whom the department executed a contract to 10 administer the Iowa high quality health care initiative as 11 established by the department, to terminate such contracts as 12 applicable to the Medicaid long-term services and supports 13 population, following a sixty-day transition period. The 14 department shall transfer the long-term services and supports 15 population to the Medicaid fee-for-service payment and delivery 16 system. The transition shall be based on a transition plan 17 developed by the department and submitted to the council on 18 human services and the medical assistance advisory council 19 for review. The department of human services shall seek any 20 Medicaid state plan or waiver amendments necessary to complete 21 the transition. 22 Sec. 2. EFFECTIVE DATE. This division of this Act, being 23 deemed of immediate importance, takes effect upon enactment. 24 DIVISION II 25 MEDICAID LONG-TERM SERVICES AND SUPPORTS POPULATION MEMBERS —— 26 PROVISION OF CONFLICT-FREE SERVICES 27 Sec. 3. MEDICAID LONG-TERM SERVICES AND SUPPORTS POPULATION 28 MEMBERS —— PROVISION OF CONFLICT-FREE SERVICES. The department 29 of human services shall adopt rules pursuant to chapter 17A to 30 ensure that services are provided under the Medicaid program to 31 members of the long-term services and supports population in a 32 conflict-free manner. Specifically, case management services 33 shall be provided by independent providers and supports 34 intensity scale assessments shall be performed by independent 35 -1- LSB 1590ST (11) 88 pf/rh 1/ 10

S.F. 156 assessors. 1 DIVISION III 2 MEDICATION-ASSISTED TREATMENT 3 Sec. 4. MEDICATION-ASSISTED TREATMENT —— PRIOR 4 AUTHORIZATION PROHIBITED. The department of human services 5 shall adopt rules pursuant to chapter 17A that prohibit 6 prior authorization for medication-assisted treatment under 7 both Medicaid fee-for-service and managed care payment and 8 delivery systems. The department of human services shall also 9 include this prohibition in any contract entered into with a 10 Medicaid managed care organization. For the purposes of this 11 section, “medication-assisted treatment” means the medically 12 monitored use of certain substance use disorder medications in 13 combination with other treatment services. 14 DIVISION IV 15 MEDICAID WORKFORCE PROGRAM 16 Sec. 5. WORKFORCE RECRUITMENT, RETENTION, AND TRAINING 17 PROGRAMS. The department of human services shall contractually 18 require any managed care organization with whom the department 19 contracts under the Medicaid program to collaborate with 20 the department and stakeholders to develop and administer a 21 workforce recruitment, retention, and training program to 22 provide adequate access to appropriate services, including 23 but not limited to services to older Iowans. The department 24 shall ensure that any program developed is administered in a 25 coordinated and collaborative manner across all contracting 26 managed care organizations and shall require the managed care 27 organizations to submit quarterly progress and outcomes reports 28 to the department. 29 DIVISION V 30 PROVIDER APPEALS PROCESS —— EXTERNAL REVIEW 31 Sec. 6. MEDICAID MANAGED CARE ORGANIZATION APPEALS PROCESS 32 —— EXTERNAL REVIEW. 33 1. a. A Medicaid managed care organization under contract 34 with the state shall include in any written response to 35 -2- LSB 1590ST (11) 88 pf/rh 2/ 10

S.F. 156 a Medicaid provider under contract with the managed care 1 organization that reflects a final adverse determination of the 2 managed care organization’s internal appeal process relative to 3 an appeal filed by the Medicaid provider, all of the following: 4 (1) A statement that the Medicaid provider’s internal 5 appeal rights within the managed care organization have been 6 exhausted. 7 (2) A statement that the Medicaid provider is entitled to 8 an external independent third-party review pursuant to this 9 section. 10 (3) The requirements for requesting an external independent 11 third-party review. 12 b. If a managed care organization’s written response does 13 not comply with the requirements of paragraph “a”, the managed 14 care organization shall pay to the affected Medicaid provider a 15 penalty not to exceed one thousand dollars. 16 2. a. A Medicaid provider who has been denied the provision 17 of a service to a Medicaid member or a claim for reimbursement 18 for a service rendered to a Medicaid member, and who has 19 exhausted the internal appeals process of a managed care 20 organization, shall be entitled to an external independent 21 third-party review of the managed care organization’s final 22 adverse determination. 23 b. To request an external independent third-party review of 24 a final adverse determination by a managed care organization, 25 an aggrieved Medicaid provider shall submit a written request 26 for such review to the managed care organization within sixty 27 calendar days of receiving the final adverse determination. 28 c. A Medicaid provider’s request for such review shall 29 include all of the following: 30 (1) Identification of each specific issue and dispute 31 directly related to the final adverse determination issued by 32 the managed care organization. 33 (2) A statement of the basis upon which the Medicaid 34 provider believes the managed care organization’s determination 35 -3- LSB 1590ST (11) 88 pf/rh 3/ 10

S.F. 156 to be erroneous. 1 (3) The Medicaid provider’s designated contact information, 2 including name, mailing address, phone number, fax number, and 3 email address. 4 3. a. Within five business days of receiving a Medicaid 5 provider’s request for review pursuant to this subsection, the 6 managed care organization shall do all of the following: 7 (1) Confirm to the Medicaid provider’s designated contact, 8 in writing, that the managed care organization has received the 9 request for review. 10 (2) Notify the department of the Medicaid provider’s 11 request for review. 12 (3) Notify the affected Medicaid member of the Medicaid 13 provider’s request for review, if the review is related to the 14 denial of a service. 15 b. If the managed care organization fails to satisfy the 16 requirements of this subsection 3, the Medicaid provider shall 17 automatically prevail in the review. 18 4. a. Within fifteen calendar days of receiving a Medicaid 19 provider’s request for external independent third-party review, 20 the managed care organization shall do all of the following: 21 (1) Submit to the department all documentation submitted 22 by the Medicaid provider in the course of the managed care 23 organization’s internal appeal process. 24 (2) Provide the managed care organization’s designated 25 contact information, including name, mailing address, phone 26 number, fax number, and email address. 27 b. If a managed care organization fails to satisfy the 28 requirements of this subsection 4, the Medicaid provider shall 29 automatically prevail in the review. 30 5. An external independent third-party review shall 31 automatically extend the deadline to file an appeal for a 32 contested case hearing under chapter 17A, pending the outcome 33 of the external independent third-party review, until thirty 34 calendar days following receipt of the review decision by the 35 -4- LSB 1590ST (11) 88 pf/rh 4/ 10

S.F. 156 Medicaid provider. 1 6. Upon receiving notification of a request for external 2 independent third-party review, the department shall do all of 3 the following: 4 a. Assign the review to an external independent third-party 5 reviewer. 6 b. Notify the managed care organization of the identity of 7 the external independent third-party reviewer. 8 c. Notify the Medicaid provider’s designated contact of the 9 identity of the external independent third-party reviewer. 10 7. The department shall deny a request for an external 11 independent third-party review if the requesting Medicaid 12 provider fails to exhaust the managed care organization’s 13 internal appeals process or fails to submit a timely request 14 for an external independent third-party review pursuant to this 15 subsection. 16 8. a. Multiple appeals through the external independent 17 third-party review process regarding the same Medicaid 18 member, a common question of fact, or interpretation of common 19 applicable regulations or reimbursement requirements may 20 be combined and determined in one action upon request of a 21 party in accordance with rules and regulations adopted by the 22 department. 23 b. The Medicaid provider that initiated a request for 24 an external independent third-party review, or one or more 25 other Medicaid providers, may add claims to such an existing 26 external independent third-party review following exhaustion 27 of any applicable managed care organization internal appeals 28 process, if the claims involve a common question of fact 29 or interpretation of common applicable regulations or 30 reimbursement requirements. 31 9. Documentation reviewed by the external independent 32 third-party reviewer shall be limited to documentation 33 submitted pursuant to subsection 4. 34 10. An external independent third-party reviewer shall do 35 -5- LSB 1590ST (11) 88 pf/rh 5/ 10

S.F. 156 all of the following: 1 a. Conduct an external independent third-party review 2 of any claim submitted to the reviewer pursuant to this 3 subsection. 4 b. Within thirty calendar days from receiving the request 5 for review from the department and the documentation submitted 6 pursuant to subsection 4, issue the reviewer’s final decision 7 to the Medicaid provider’s designated contact, the managed 8 care organization’s designated contact, the department, and 9 the affected Medicaid member if the decision involves a denial 10 of service. The reviewer may extend the time to issue a final 11 decision by fourteen calendar days upon agreement of all 12 parties to the review. 13 11. The department shall enter into a contract with 14 an independent review organization that does not have a 15 conflict of interest with the department or any managed care 16 organization to conduct the independent third-party reviews 17 under this section. 18 a. A party, including the affected Medicaid member or 19 Medicaid provider, may appeal a final decision of the external 20 independent third-party reviewer in a contested case proceeding 21 in accordance with chapter 17A within thirty calendar days from 22 receiving the final decision. A final decision in a contested 23 case proceeding is subject to judicial review. 24 b. The final decision of any external independent 25 third-party review conducted pursuant to this subsection shall 26 also direct the nonprevailing party to pay an amount equal to 27 the costs of the review to the external independent third-party 28 reviewer. Any payment ordered pursuant to this subsection 29 shall be stayed pending any appeal of the review. If the 30 final outcome of any appeal is to reverse the decision of the 31 external independent third-party review, the nonprevailing 32 party shall pay the costs of the review to the external 33 independent third-party reviewer within forty-five calendar 34 days of entry of the final order. 35 -6- LSB 1590ST (11) 88 pf/rh 6/ 10

S.F. 156 DIVISION VI 1 MEMBER DISENROLLMENT FOR GOOD CAUSE 2 Sec. 7. MEMBER DISENROLLMENT FOR GOOD CAUSE. The department 3 of human services shall adopt rules pursuant to chapter 17A 4 and shall contractually require all Medicaid managed care 5 organizations to issue a decision in response to a member’s 6 request for disenrollment for good cause within ten days 7 of the date the member submits the request to the Medicaid 8 managed care organization utilizing the Medicaid managed care 9 organization’s grievance process. 10 DIVISION VII 11 OMBUDSMAN —— MEDICAID PROGRAM ASSISTANCE AND ADVOCACY 12 Sec. 8. NEW SECTION . 2C.6A Assistant for Medicaid program. 13 1. The ombudsman shall appoint an assistant who shall be 14 primarily responsible for investigating complaints relating to 15 the Medicaid program, including both Medicaid fee-for-service 16 and managed care payment and delivery systems, and all Medicaid 17 populations including the long-term services and supports 18 population. 19 2. The ombudsman shall provide assistance and advocacy 20 services to Medicaid recipients and the families or legal 21 representatives of Medicaid recipients. Such assistance 22 and advocacy shall include but is not limited to all of the 23 following: 24 a. Assisting recipients in understanding the services, 25 coverage, and access provisions and their rights under the 26 Medicaid program. 27 b. Developing procedures for the tracking and reporting 28 of the outcomes of individual requests for assistance, the 29 procedures available for obtaining services, and other aspects 30 of the services provided to Medicaid recipients. 31 c. Providing advice and assistance relating to the 32 preparation and filing of complaints, grievances, and appeals 33 of complaints or grievances, including through processes 34 available under managed care plans and the state appeals 35 -7- LSB 1590ST (11) 88 pf/rh 7/ 10

S.F. 156 process under the Medicaid program. 1 3. The ombudsman shall adopt rules to administer this 2 section. 3 4. The ombudsman shall publish special reports and 4 investigative reports as deemed necessary and shall include 5 findings and recommendations related to the assistance and 6 advocacy provided under this section in the ombudsman’s annual 7 report. 8 Sec. 9. REPEAL. Section 231.44, Code 2019, is repealed. 9 EXPLANATION 10 The inclusion of this explanation does not constitute agreement with 11 the explanation’s substance by the members of the general assembly. 12 This bill relates to the Medicaid program. 13 Division I of the bill requires the department of human 14 services (DHS) to terminate existing contracts with Medicaid 15 managed care organizations (MCOs) as the contracts apply to 16 the Medicaid long-term services and supports population and 17 transfer this population from the Medicaid managed care to the 18 Medicaid fee-for-service payment and delivery system. The 19 transition is to be based on a transition plan developed by DHS 20 and submitted to the council on human services and the medical 21 assistance advisory council for review. DHS is required to 22 seek any Medicaid state plan or waiver amendments as necessary 23 to complete the transition. The division takes effect upon 24 enactment. 25 Division II of the bill requires DHS to adopt administrative 26 rules to ensure that services are provided to the Medicaid 27 long-term services and supports population in a conflict-free 28 manner. Specifically, the bill requires that case management 29 services shall be provided by independent providers and that 30 the supports intensity scale assessments are performed by 31 independent assessors. 32 Division III of the bill relates to medication-assisted 33 treatment. The bill requires DHS to adopt administrative 34 rules to prohibit prior authorization for the provision 35 -8- LSB 1590ST (11) 88 pf/rh 8/ 10

S.F. 156 of medication-assisted treatment under both the Medicaid 1 fee-for-service and managed care payment and delivery systems. 2 The division also requires DHS to include this prohibition 3 in any contract entered into with a Medicaid MCO. Under the 4 division, “medication-assisted treatment” means the medically 5 monitored use of certain substance use disorder medications in 6 combination with other treatment services. 7 Division IV of the bill requires DHS to contractually 8 require any Medicaid MCO to collaborate with the department and 9 stakeholders to develop and administer a workforce recruitment, 10 retention, and training program to provide adequate access to 11 appropriate services, including but not limited to services 12 to older Iowans. The department shall ensure that any such 13 program developed is administered in a coordinated and 14 collaborative manner across all contracting MCOs and shall 15 require the MCOs to submit quarterly progress and outcomes 16 reports to the department. 17 Division V of the bill establishes an external review 18 process for Medicaid providers for the review of final adverse 19 determinations of the MCOs’ internal appeal processes. The 20 division provides that a final decision of an external reviewer 21 may be reviewed in a contested case proceeding pursuant to Code 22 chapter 17A, and ultimately is subject to judicial review. 23 Division VI of the bill relates to member disenrollment for 24 good cause during the 12 months of closed enrollment between 25 open enrollment periods. Currently, a member may request 26 disenrollment for good cause initially through their MCO’s 27 grievance process, which may take up to 30 to 45 days to 28 process. The bill requires DHS to adopt administrative rules 29 and contractually require all Medicaid MCOs to issue a decision 30 in response to a member’s request for disenrollment for good 31 cause within 10 days of the date the member submits the request 32 to the MCO utilizing the MCO’s grievance process. 33 Division VII of the bill directs the ombudsman to appoint an 34 assistant who shall be primarily responsible for investigating 35 -9- LSB 1590ST (11) 88 pf/rh 9/ 10

S.F. 156 complaints relating to the Medicaid program, including both 1 the Medicaid managed care and fee-for-service payment and 2 delivery systems, and all Medicaid populations including the 3 long-term services and supports population. The division 4 specifies the minimum areas of assistance and advocacy to be 5 provided, directs the ombudsman to adopt administrative rules 6 for administration of this division of the bill, and directs 7 the ombudsman to publish special reports and investigative 8 reports as deemed necessary, and to include findings and 9 recommendations related to the Medicaid program assistance and 10 advocacy provided under the bill in the ombudsman’s annual 11 report. 12 The division also repeals the section of the Code that 13 directs the office of long-term care ombudsman to provide 14 assistance and advocacy services to members of the Medicaid 15 long-term services and supports population since under the 16 bill, the ombudsman will provide assistance and advocacy 17 for both Medicaid managed care and fee-for-service payment 18 and delivery systems and for all populations including the 19 long-term services and supports population. 20 -10- LSB 1590ST (11) 88 pf/rh 10/ 10