S.F. 420 DIVISION I 1 MEDICAID PRIOR AUTHORIZATION 2 Section 1. MEDICAID —— PRIOR AUTHORIZATION UNIFORM 3 PROCESS. The department of human services shall adopt rules 4 pursuant to chapter 17A to require, and shall contractually 5 require, that both managed care and fee-for-service payment 6 and delivery systems utilize a uniform process, including but 7 not limited to uniform forms, information requirements, and 8 time frames, to request prior authorization under the Medicaid 9 program. 10 DIVISION II 11 MEDICAID PROGRAM OMBUDSMAN 12 Sec. 2. 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 -1- LSB 2687XS (3) 88 pf/rh 1/ 5

S.F. 420 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 5. The ombudsman and the department of human services 9 shall collaborate to develop a cost allocation plan requesting 10 Medicaid administrative funding to provide for the claiming of 11 federal financial participation for ombudsman activities that 12 are performed to assist with the administration of the Medicaid 13 program. The cost allocation plan shall document the costs 14 that directly benefit the Medicaid program and are consistent 15 with federal requirements. The cost allocation plan shall be 16 developed in a timely manner to allow for such claiming to 17 begin by January 1, 2020. 18 Sec. 3. REPEAL. Section 231.44, Code 2019, is repealed. 19 DIVISION III 20 MEDICAID MANAGED CARE —— EXTERNAL REVIEW OF PROVIDER-DENIED 21 CLAIMS 22 Sec. 4. MEDICAID MANAGED CARE —— EXTERNAL REVIEW OF 23 PROVIDER-DENIED CLAIMS. 24 1. The department of human services shall contractually 25 require a Medicaid managed care organization to utilize an 26 external review process in accordance with rules adopted by 27 the department pursuant to chapter 17A. The external review 28 process shall provide for review by an independent third party 29 of a Medicaid provider’s claims denied by the Medicaid managed 30 care organization and following a final adverse determination 31 of the managed care organization’s internal appeal process. 32 2. The external review process shall provide for all of the 33 following: 34 a. A request for an external review shall automatically 35 -2- LSB 2687XS (3) 88 pf/rh 2/ 5

S.F. 420 extend the deadline to file an appeal for a contested case 1 hearing under chapter 17A, pending the outcome of the external 2 review, until thirty calendar days following receipt of the 3 final decision by the Medicaid provider. 4 b. Upon receipt of a request from a Medicaid provider for 5 external review, the department shall assign the review to 6 an external independent third-party reviewer, and notify the 7 applicable Medicaid managed care organization and the Medicaid 8 provider of the identity of the external reviewer. 9 c. Within fifteen calendar days of notification of a 10 Medicaid provider’s request for external review, the managed 11 care organization shall submit to the external reviewer all 12 documentation submitted by the Medicaid provider in the course 13 of the internal appeal process. 14 d. Within thirty calendar days of receiving all 15 documentation from the applicable Medicaid managed care 16 organization submitted by the Medicaid provider in the course 17 of the internal appeal process, the external reviewer shall 18 issue a final decision to the Medicaid provider, the applicable 19 Medicaid managed care organization, and the department. The 20 reviewer may extend the time to issue a final decision by 21 fourteen calendar days upon agreement of all parties to the 22 review. 23 e. A party may appeal a final decision of the external 24 reviewer in a contested case proceeding in accordance with 25 chapter 17A within thirty calendar days from receipt of the 26 final decision by the Medicaid provider. A final decision in a 27 contested case proceeding is subject to judicial review. 28 3. The department shall enter into a contract with a review 29 organization that does not have a conflict of interest with 30 the department or any managed care organization to conduct the 31 independent third-party reviews under this section. 32 EXPLANATION 33 The inclusion of this explanation does not constitute agreement with 34 the explanation’s substance by the members of the general assembly. 35 -3- LSB 2687XS (3) 88 pf/rh 3/ 5

S.F. 420 Division I of this bill requires the department of human 1 services (DHS) to adopt administrative rules to require, 2 and to contractually require, that both managed care and 3 fee-for-service payment and delivery systems utilize a 4 uniform process, including but not limited to uniform forms, 5 information requirements, and time frames, to request prior 6 authorization under the Medicaid program. 7 Division II of the bill directs the ombudsman to appoint an 8 assistant who shall be primarily responsible for investigating 9 complaints relating to the Medicaid program, including both 10 the Medicaid managed care and fee-for-service payment and 11 delivery systems, and all Medicaid populations including the 12 long-term services and supports population. The division 13 specifies the minimum areas of assistance and advocacy to be 14 provided, directs the ombudsman to adopt administrative rules 15 for administration of the division, and directs the ombudsman 16 to publish special reports and investigative reports as deemed 17 necessary, and to include findings and recommendations related 18 to the Medicaid program assistance and advocacy provided under 19 the division in the ombudsman’s annual report. 20 The division also repeals the section of the Code that 21 directs the office of long-term care ombudsman to provide 22 assistance and advocacy services to members of the Medicaid 23 long-term services and supports population since under the 24 division, the ombudsman will provide assistance and advocacy 25 for both Medicaid managed care and fee-for-service payment 26 and delivery systems and for all populations including the 27 long-term services and supports population. 28 The division also requires the ombudsman and DHS to 29 collaborate to develop a cost allocation plan, consistent 30 with federal requirements, requesting Medicaid administrative 31 funding to provide for the claiming of federal financial 32 participation, by January 1, 2020, for ombudsman activities 33 that are performed to assist with administration of the 34 Medicaid program. 35 -4- LSB 2687XS (3) 88 pf/rh 4/ 5

S.F. 420 Division III of the bill requires DHS to contractually 1 require a Medicaid managed care organization (MCO) to utilize 2 an external review process in accordance with administrative 3 rules adopted by DHS, to provide for a review by an independent 4 third-party reviewer of a Medicaid provider’s claims denied by 5 an MCO and following a final adverse determination of the MCO’s 6 internal appeal process. The bill specifies what the external 7 review process, at a minimum, shall provide for, and directs 8 DHS to enter into a contract with a review organization that 9 does not have a conflict of interest with DHS or any MCO to 10 conduct the independent third-party reviews under the bill. 11 -5- LSB 2687XS (3) 88 pf/rh 5/ 5