SF 468 (LSB 1022XS (4) 88)

SENATE FILE 468

BY  BROWN

A BILL FOR

An Act relating to an administrative services organization delivery model for the Medicaid program, and including effective date provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

DIVISION I
ADMINISTRATIVE SERVICES ORGANIZATION DELIVERY MODEL FOR MEDICAID PROGRAM

    Section 1.  Section 249A.4, subsection 4, Code 2019, is amended by striking the subsection.
    Sec. 2.  NEW SECTION.  249A.4A  Administrative services organization —— managed fee-for-service value-based delivery model —— Medicaid program.
   1.  The department of human services shall issue a request for proposals and enter into contracts as necessary effective July 1, 2020, to provide a managed fee-for-service value-based delivery model utilizing an administrative services organization to coordinate delivery of physical health and behavioral health services for the Medicaid program.
   2.  An administrative services organization under contract with the state shall not have any financial incentive to approve, deny, or reduce services, and shall ensure that service providers and persons seeking services have timely access to program information and timely responses to inquiries, including inquiries concerning clinical guidelines for services and reimbursement.
    Sec. 3.  EFFECTIVE DATE.  This division of this Act takes effect July 1, 2020.
DIVISION II
DEVELOPMENT OF REQUEST FOR PROPOSALS —— ADMINISTRATIVE SERVICES ORGANIZATION DELIVERY MODEL FOR MEDICAID PROGRAM

    Sec. 4.  DEVELOPMENT OF REQUEST FOR PROPOSALS TO CONTRACT FOR ADMINISTRATIVE SERVICES ORGANIZATION DELIVERY MODEL FOR MEDICAID PROGRAM.
   1.  The department of human services shall contract with the university of Iowa public policy center to assist in developing a request for proposals to be issued no later than January 1, 2020, as the basis for soliciting bids from entities to contract for and implement a managed fee-for-service value-based delivery model, utilizing an administrative services organization for the Medicaid program in place of Medicaid managed care beginning July 1, 2020. The public policy center shall convene a request for proposals development work group consisting of representatives of the Iowa hospital association, the medical assistance advisory council created pursuant to section 249A.4B, the patient-centered health advisory council created pursuant to section 135.159, and other stakeholders to develop the request for proposals. The work group shall consider the experiences of other states such as Connecticut and Colorado that utilize administrative services organization Medicaid service delivery models. The goals of the delivery system shall be to centralize management of physical and behavioral services for all managed Medicaid beneficiaries thereby increasing program consistency, streamlining member and provider support, and reducing uncertainty; to employ a single, fully integrated set of data which spans all coverage groups and covered services to increase the use of predictive modeling tools to inform risk stratification and policy decisions that yield improved health outcomes and beneficiary experiences; and to build and sustain community partnerships and expand value-based delivery of services.
   2.  All of the following shall be considered in developing the request for proposals pursuant to subsection 1:
   a.  The key elements for the delivery system including all of the following:
   (1)  A simplified administrative structure utilizing an administrative services organization to effectively support and empower both members and providers.
   (2)  A fully integrated claims database and statewide data analytics infrastructure.
   (3)  A strong emphasis on prevention.
   (4)  A focus on integration of all health services including medical, behavioral, and dental services with social services.
   (5)  A long-term services and supports system that enables true choice and integration.
   b.  An infrastructure that provides all of the following:
   (1)  A single statewide data analytics infrastructure. The statewide data analytics infrastructure may be managed by the department of human services internally or through a contractor. The infrastructure shall support information exchange among Medicaid providers, allow providers across the continuum to participate in health information exchange, and provide data analytics that incorporate both medical and social determinants of health to inform population health management efforts, illuminate needs, inform policy direction, support cost savings, and ensure accountability through transparent external reporting to state regulators and stakeholders. The statewide data analytics platform shall also enable providers to track patient care patterns, identify areas of need, and evaluate the impact of provider initiatives.
   (2)  A statewide administrative services organization. An established administrative services organization shall act as a single, statewide entity to provide consistent, centralized, and streamlined administrative functions for all Medicaid providers and members. The administrative services organization shall receive monthly administrative payments and may receive a percentage of a payment contingent on meeting performance metrics as defined in the contract. The administrative services organization may provide such services as planning and marketing, human resources management, regulatory compliance, development of information systems, contract management, provider and member services, claims administration, data reporting, utilization management, quality management, intensive care management, review of grievances, provider network development and management, credentialing of providers, reporting, and other services.
   (a)  The administrative services organization shall also provide a statewide framework and infrastructure for care management and coordination across all populations and services, including a standardized set of quality measures, clinical guidelines, and care improvement initiatives, while providing flexibility for local variation and innovation and generating the provision of care management locally, at the site of care. The administrative services organization infrastructure and resources shall be developed in collaboration with providers, members, and other stakeholders, and shall take into consideration the unique needs and priorities of smaller providers and rural settings.
   (b)  The administrative services organization shall address statewide population health improvement by doing all of the following:
   (i)  Developing targeted statewide population health-based performance goals and a coordinated infrastructure to support providers in achieving these goals. The coordinated infrastructure shall provide for the development of partnerships with community-based organizations to address the full array of social determinants of health and for the utilization of robust care coordination that employs a standard social and health assessment, provides for referral to health and social services, and tracks outcomes. Goals shall be informed by state innovation model efforts and by community health needs assessments and community health improvement plans conducted by hospitals and local public health agencies.
   (ii)  In collaboration with Iowa hospitals, physicians, health care providers, and other entities that support Medicaid recipients, serving as a unified administrative support system and accelerator for provider-led initiatives to advance care management, practice transformation, and value-based payment objectives.
   (iii)  Developing and maintaining a coordinated statewide network of qualified and licensed service providers to ensure appropriate, local access to care.
   (3)  A statewide strategy for the adoption and advancement of value-based payment models, taking into account the diversity in provider readiness across the state.
   The statewide strategy shall provide for payment models that build upon the fee-for-service reimbursement model including a uniform fee schedule, annual reimbursement updates, and cost-based reimbursement for critical access hospitals and shall transition providers to value-based payment arrangements over time, taking into account accommodations for small and rural providers to ensure the strategy is responsive to provider capabilities and the needs of specific communities. The strategic provider-led care improvement initiatives shall be developed and implemented utilizing the centralized resources of the administrative services organization and shall provide for partnership with providers across the continuum of care incorporating clinical services and nonclinical community and social supports to address the whole patient.
   (4)  Enhanced state oversight and accountability.
   State oversight and accountability measures shall, at a minimum, do all of the following:
   (a)  Ensure state and public access to timely, accurate, and actionable data regarding utilization and quality.
   (b)  Establish mechanisms that require the sharing of information regarding performance and internal processes, policies, and decisions that may affect quality and access to care.
   (c)  Establish mechanisms that support candid communication between the state and stakeholders to encourage trust and a vested interest in the success of the program.
   (d)  Provide for monitoring of the administrative services organization including through review of service authorizations, individual outcomes, appeals, outreach and accessibility, and comments from members and providers compiled from written surveys and face-to-face interviews.
   c.  The role of state agencies. The request for proposals shall require collaboration across state departments and the utilization of the membership of the patient-centered health advisory council established pursuant to section 135.159 and the medical assistance advisory council established pursuant to section 249A.4B to directly engage experts in determining and addressing data analytics needs; developing and implementing standardized quality measures, clinical guidelines, a credentialing process, a social determinants of health assessment, and strategic provider-led care improvement initiatives that lead to population health improvement; and the implementation and progress of the structure and key elements of the Medicaid delivery system established.
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 the development and implementation of a managed fee-for-service value-based delivery model utilizing an administrative services organization.
   Division I of the bill requires the department of human services (DHS) to issue a request for proposals and enter into contracts as necessary effective July 1, 2020, to provide a managed fee-for-service value-based delivery model utilizing an administrative services organization to coordinate delivery of physical and behavioral health services for the Medicaid program. The bill also strikes current Code language that authorizes the DHS director to contract with corporations authorized to insure groups or individuals; corporations maintaining and operating medical, hospital, or health service prepayment plans; or health maintenance organizations to provide coverage for Medicaid members. This division takes effect July 1, 2020.
   Division II of the bill requires DHS to contract with the university of Iowa public policy center to assist in developing a request for proposals (RFP) to be issued no later than January 1, 2020, as the basis for soliciting bids from entities to contract for and implement a managed fee-for-service value-based delivery model utilizing an administrative services organization for the Medicaid program in place of Medicaid managed care beginning July 1, 2020. The public policy center is required to convene a request for proposals development work group to develop the RFP. The bill describes the goals of the delivery system and requires the work group to consider the key elements for the delivery system; the infrastructure for the delivery system including a single statewide data analytics infrastructure, a statewide administrative services organization, a statewide strategy for the adoption and advancement of value-based payment models, and enhanced state oversight and accountability; and the role of state agencies.