S.F. 468 DIVISION I 1 ADMINISTRATIVE SERVICES ORGANIZATION DELIVERY MODEL FOR 2 MEDICAID PROGRAM 3 Section 1. Section 249A.4, subsection 4, Code 2019, is 4 amended by striking the subsection. 5 Sec. 2. NEW SECTION . 249A.4A Administrative services 6 organization —— managed fee-for-service value-based delivery 7 model —— Medicaid program. 8 1. The department of human services shall issue a 9 request for proposals and enter into contracts as necessary 10 effective July 1, 2020, to provide a managed fee-for-service 11 value-based delivery model utilizing an administrative services 12 organization to coordinate delivery of physical health and 13 behavioral health services for the Medicaid program. 14 2. An administrative services organization under contract 15 with the state shall not have any financial incentive to 16 approve, deny, or reduce services, and shall ensure that 17 service providers and persons seeking services have timely 18 access to program information and timely responses to 19 inquiries, including inquiries concerning clinical guidelines 20 for services and reimbursement. 21 Sec. 3. EFFECTIVE DATE. This division of this Act takes 22 effect July 1, 2020. 23 DIVISION II 24 DEVELOPMENT OF REQUEST FOR PROPOSALS —— ADMINISTRATIVE SERVICES 25 ORGANIZATION DELIVERY MODEL FOR MEDICAID PROGRAM 26 Sec. 4. DEVELOPMENT OF REQUEST FOR PROPOSALS TO CONTRACT 27 FOR ADMINISTRATIVE SERVICES ORGANIZATION DELIVERY MODEL FOR 28 MEDICAID PROGRAM. 29 1. The department of human services shall contract with 30 the university of Iowa public policy center to assist in 31 developing a request for proposals to be issued no later than 32 January 1, 2020, as the basis for soliciting bids from entities 33 to contract for and implement a managed fee-for-service 34 value-based delivery model, utilizing an administrative 35 -1- LSB 1022XS (4) 88 pf/rh 1/ 7

S.F. 468 services organization for the Medicaid program in place of 1 Medicaid managed care beginning July 1, 2020. The public 2 policy center shall convene a request for proposals development 3 work group consisting of representatives of the Iowa hospital 4 association, the medical assistance advisory council created 5 pursuant to section 249A.4B, the patient-centered health 6 advisory council created pursuant to section 135.159, and 7 other stakeholders to develop the request for proposals. The 8 work group shall consider the experiences of other states 9 such as Connecticut and Colorado that utilize administrative 10 services organization Medicaid service delivery models. 11 The goals of the delivery system shall be to centralize 12 management of physical and behavioral services for all 13 managed Medicaid beneficiaries thereby increasing program 14 consistency, streamlining member and provider support, and 15 reducing uncertainty; to employ a single, fully integrated set 16 of data which spans all coverage groups and covered services 17 to increase the use of predictive modeling tools to inform 18 risk stratification and policy decisions that yield improved 19 health outcomes and beneficiary experiences; and to build and 20 sustain community partnerships and expand value-based delivery 21 of services. 22 2. All of the following shall be considered in developing 23 the request for proposals pursuant to subsection 1: 24 a. The key elements for the delivery system including all 25 of the following: 26 (1) A simplified administrative structure utilizing an 27 administrative services organization to effectively support and 28 empower both members and providers. 29 (2) A fully integrated claims database and statewide data 30 analytics infrastructure. 31 (3) A strong emphasis on prevention. 32 (4) A focus on integration of all health services including 33 medical, behavioral, and dental services with social services. 34 (5) A long-term services and supports system that enables 35 -2- LSB 1022XS (4) 88 pf/rh 2/ 7

S.F. 468 true choice and integration. 1 b. An infrastructure that provides all of the following: 2 (1) A single statewide data analytics infrastructure. 3 The statewide data analytics infrastructure may be managed 4 by the department of human services internally or through a 5 contractor. The infrastructure shall support information 6 exchange among Medicaid providers, allow providers across the 7 continuum to participate in health information exchange, and 8 provide data analytics that incorporate both medical and social 9 determinants of health to inform population health management 10 efforts, illuminate needs, inform policy direction, support 11 cost savings, and ensure accountability through transparent 12 external reporting to state regulators and stakeholders. The 13 statewide data analytics platform shall also enable providers 14 to track patient care patterns, identify areas of need, and 15 evaluate the impact of provider initiatives. 16 (2) A statewide administrative services organization. 17 An established administrative services organization shall 18 act as a single, statewide entity to provide consistent, 19 centralized, and streamlined administrative functions for 20 all Medicaid providers and members. The administrative 21 services organization shall receive monthly administrative 22 payments and may receive a percentage of a payment contingent 23 on meeting performance metrics as defined in the contract. 24 The administrative services organization may provide such 25 services as planning and marketing, human resources management, 26 regulatory compliance, development of information systems, 27 contract management, provider and member services, claims 28 administration, data reporting, utilization management, quality 29 management, intensive care management, review of grievances, 30 provider network development and management, credentialing of 31 providers, reporting, and other services. 32 (a) The administrative services organization shall also 33 provide a statewide framework and infrastructure for care 34 management and coordination across all populations and 35 -3- LSB 1022XS (4) 88 pf/rh 3/ 7

S.F. 468 services, including a standardized set of quality measures, 1 clinical guidelines, and care improvement initiatives, 2 while providing flexibility for local variation and 3 innovation and generating the provision of care management 4 locally, at the site of care. The administrative services 5 organization infrastructure and resources shall be developed in 6 collaboration with providers, members, and other stakeholders, 7 and shall take into consideration the unique needs and 8 priorities of smaller providers and rural settings. 9 (b) The administrative services organization shall address 10 statewide population health improvement by doing all of the 11 following: 12 (i) Developing targeted statewide population health-based 13 performance goals and a coordinated infrastructure to 14 support providers in achieving these goals. The coordinated 15 infrastructure shall provide for the development of 16 partnerships with community-based organizations to address 17 the full array of social determinants of health and for the 18 utilization of robust care coordination that employs a standard 19 social and health assessment, provides for referral to health 20 and social services, and tracks outcomes. Goals shall be 21 informed by state innovation model efforts and by community 22 health needs assessments and community health improvement plans 23 conducted by hospitals and local public health agencies. 24 (ii) In collaboration with Iowa hospitals, physicians, 25 health care providers, and other entities that support Medicaid 26 recipients, serving as a unified administrative support system 27 and accelerator for provider-led initiatives to advance care 28 management, practice transformation, and value-based payment 29 objectives. 30 (iii) Developing and maintaining a coordinated statewide 31 network of qualified and licensed service providers to ensure 32 appropriate, local access to care. 33 (3) A statewide strategy for the adoption and advancement of 34 value-based payment models, taking into account the diversity 35 -4- LSB 1022XS (4) 88 pf/rh 4/ 7

S.F. 468 in provider readiness across the state. 1 The statewide strategy shall provide for payment models that 2 build upon the fee-for-service reimbursement model including 3 a uniform fee schedule, annual reimbursement updates, and 4 cost-based reimbursement for critical access hospitals and 5 shall transition providers to value-based payment arrangements 6 over time, taking into account accommodations for small 7 and rural providers to ensure the strategy is responsive to 8 provider capabilities and the needs of specific communities. 9 The strategic provider-led care improvement initiatives 10 shall be developed and implemented utilizing the centralized 11 resources of the administrative services organization and shall 12 provide for partnership with providers across the continuum of 13 care incorporating clinical services and nonclinical community 14 and social supports to address the whole patient. 15 (4) Enhanced state oversight and accountability. 16 State oversight and accountability measures shall, at a 17 minimum, do all of the following: 18 (a) Ensure state and public access to timely, accurate, and 19 actionable data regarding utilization and quality. 20 (b) Establish mechanisms that require the sharing of 21 information regarding performance and internal processes, 22 policies, and decisions that may affect quality and access to 23 care. 24 (c) Establish mechanisms that support candid communication 25 between the state and stakeholders to encourage trust and a 26 vested interest in the success of the program. 27 (d) Provide for monitoring of the administrative 28 services organization including through review of service 29 authorizations, individual outcomes, appeals, outreach and 30 accessibility, and comments from members and providers compiled 31 from written surveys and face-to-face interviews. 32 c. The role of state agencies. The request for proposals 33 shall require collaboration across state departments and the 34 utilization of the membership of the patient-centered health 35 -5- LSB 1022XS (4) 88 pf/rh 5/ 7

S.F. 468 advisory council established pursuant to section 135.159 1 and the medical assistance advisory council established 2 pursuant to section 249A.4B to directly engage experts in 3 determining and addressing data analytics needs; developing 4 and implementing standardized quality measures, clinical 5 guidelines, a credentialing process, a social determinants of 6 health assessment, and strategic provider-led care improvement 7 initiatives that lead to population health improvement; and the 8 implementation and progress of the structure and key elements 9 of the Medicaid delivery system established. 10 EXPLANATION 11 The inclusion of this explanation does not constitute agreement with 12 the explanation’s substance by the members of the general assembly. 13 This bill relates to the development and implementation of a 14 managed fee-for-service value-based delivery model utilizing an 15 administrative services organization. 16 Division I of the bill requires the department of human 17 services (DHS) to issue a request for proposals and enter into 18 contracts as necessary effective July 1, 2020, to provide a 19 managed fee-for-service value-based delivery model utilizing 20 an administrative services organization to coordinate delivery 21 of physical and behavioral health services for the Medicaid 22 program. The bill also strikes current Code language that 23 authorizes the DHS director to contract with corporations 24 authorized to insure groups or individuals; corporations 25 maintaining and operating medical, hospital, or health service 26 prepayment plans; or health maintenance organizations to 27 provide coverage for Medicaid members. This division takes 28 effect July 1, 2020. 29 Division II of the bill requires DHS to contract with the 30 university of Iowa public policy center to assist in developing 31 a request for proposals (RFP) to be issued no later than 32 January 1, 2020, as the basis for soliciting bids from entities 33 to contract for and implement a managed fee-for-service 34 value-based delivery model utilizing an administrative services 35 -6- LSB 1022XS (4) 88 pf/rh 6/ 7

S.F. 468 organization for the Medicaid program in place of Medicaid 1 managed care beginning July 1, 2020. The public policy center 2 is required to convene a request for proposals development 3 work group to develop the RFP. The bill describes the goals 4 of the delivery system and requires the work group to consider 5 the key elements for the delivery system; the infrastructure 6 for the delivery system including a single statewide data 7 analytics infrastructure, a statewide administrative services 8 organization, a statewide strategy for the adoption and 9 advancement of value-based payment models, and enhanced state 10 oversight and accountability; and the role of state agencies. 11 -7- LSB 1022XS (4) 88 pf/rh 7/ 7