House File 2399 - Introduced HOUSE FILE 2399 BY COMMITTEE ON COMMERCE (SUCCESSOR TO HSB 650) A BILL FOR An Act relating to reimbursement for health care services 1 provided after receipt of a prior authorization, and 2 including applicability provisions. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 4 TLSB 5949HV (2) 89 ko/rn

H.F. 2399 Section 1. NEW SECTION . 514F.8 Prior authorizations —— 1 reimbursement. 2 1. For purposes of this section: 3 a. “Covered person” means a policyholder, subscriber, 4 enrollee, or other individual participating in a health benefit 5 plan. 6 b. “Facility” means the same as defined in section 514J.102. 7 c. “Health benefit plan” means the same as defined in 8 section 514J.102. 9 d. “Health care professional” means the same as defined in 10 section 514J.102. 11 e. “Health care provider” means a health care professional 12 or a facility. 13 f. “Health care services” means services provided by a 14 health care provider for the diagnosis, prevention, treatment, 15 cure, or relief of a health condition, illness, injury, or 16 disease. “Health care services” includes the provision of 17 durable medical equipment. 18 g. “Health carrier” means an entity subject to the 19 insurance laws and regulations of this state, or subject 20 to the jurisdiction of the commissioner, including an 21 insurance company offering sickness and accident plans, a 22 health maintenance organization, a nonprofit health service 23 corporation, a plan established pursuant to chapter 509A 24 for public employees, or any other entity providing a plan 25 of health insurance, health care benefits, or health care 26 services. “Health carrier ” does not include the department 27 of human services, or a managed care organization acting 28 pursuant to a contract with the department of human services to 29 administer the medical assistance program under chapter 249A 30 or the healthy and well kids in Iowa (hawk-i) program under 31 chapter 514I. 32 h. “Prior authorization” means a determination by a 33 utilization review organization that a specific health care 34 service proposed by a health care provider for a covered person 35 -1- LSB 5949HV (2) 89 ko/rn 1/ 4

H.F. 2399 is medically necessary or medically appropriate, and the 1 determination is made prior to the provision of the health care 2 service to the covered person, and, if applicable, includes a 3 utilization review organization’s requirement that a covered 4 person or a health care provider notify the utilization review 5 organization prior to receiving or providing a specific health 6 care service. 7 i. “Utilization review” means a program or process by which 8 an evaluation is made of the necessity, appropriateness, and 9 efficiency of the use of health care services proposed by a 10 health care provider to be provided to an individual. 11 j. “Utilization review organization” means an entity that 12 performs utilization review, including a health carrier that 13 meets the requirements established for accreditation set by the 14 utilization review accreditation commission or the national 15 committee on quality assurance and that performs utilization 16 review for the health carrier’s health benefit plans. 17 2. a. Except in a case where the health care provider 18 or the covered person has committed fraud, a utilization 19 review organization shall not revoke, or impose a limitation, 20 condition, or restriction on, a prior authorization after the 21 date on which a health care provider provides a health care 22 service to a covered person per the prior authorization. 23 b. A health carrier shall reimburse a health care provider 24 at the contracted reimbursement rate for a health care service 25 provided by the health care provider to a covered person per 26 a prior authorization. 27 3. A prior authorization for a specific health care service 28 for a covered person shall be valid for the specific health 29 care service for not less than ninety days from the date 30 that the covered person’s health care provider receives the 31 prior authorization from a utilization review organization, 32 provided that during the ninety days the covered person remains 33 a participant in the same health benefit plan in which the 34 covered person participated on the date the prior authorization 35 -2- LSB 5949HV (2) 89 ko/rn 2/ 4

H.F. 2399 was received by the health care provider. 1 4. The commissioner may adopt rules pursuant to chapter 17A 2 as necessary to administer this chapter. 3 Sec. 2. APPLICABILITY. This Act applies January 1, 2023, to 4 health benefit plans that are delivered, issued for delivery, 5 continued, or renewed in this state on or after that date. 6 EXPLANATION 7 The inclusion of this explanation does not constitute agreement with 8 the explanation’s substance by the members of the general assembly. 9 This bill is related to reimbursement for health care 10 services provided after receipt of a prior authorization. 11 Except in a case where the health care provider or the 12 covered person has committed fraud, the bill prohibits a 13 utilization review organization from revoking, or imposing a 14 limitation, condition, or restriction on a prior authorization 15 after the date on which a health care provider provides 16 a health care service to a covered person per the prior 17 authorization. The bill requires a health carrier to reimburse 18 a health care provider at the contracted reimbursement rate for 19 a health care service provided by the provider to a covered 20 person per a prior authorization. “Covered person”, “health 21 benefit plan”, “health care provider”, “health care services”, 22 “health carrier”, “prior authorization”, “utilization review”, 23 and “utilization review organization” are defined in the bill. 24 The bill provides that a prior authorization for a specific 25 health care service for a specific covered person shall be 26 valid for not less than 90 days from the date that the covered 27 person’s health care provider receives the prior authorization 28 from a utilization review organization, provided that during 29 the 90 days the covered person remains a participant in 30 the same health benefit plan in which the covered person 31 participated on the date the prior authorization was received 32 by the health care provider. 33 The commissioner of insurance may adopt rules as necessary 34 to administer the bill. 35 -3- LSB 5949HV (2) 89 ko/rn 3/ 4

H.F. 2399 The bill applies to health benefit plans that are delivered, 1 issued for delivery, continued, or renewed in this state on or 2 after January 1, 2023. 3 -4- LSB 5949HV (2) 89 ko/rn 4/ 4