House Study Bill 650 - Introduced HOUSE FILE _____ BY (PROPOSED COMMITTEE ON COMMERCE BILL BY CHAIRPERSON LUNDGREN) 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 5949YC (2) 89 ko/rn

H.F. _____ Section 1. NEW SECTION . 514F.8 Preauthorizations —— 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 dental care services, 17 pharmaceutical products or services, and the provision of 18 durable medical equipment. 19 g. “Health carrier” means the same as defined in section 20 514J.102. 21 h. “Prior authorization” means a determination by a 22 utilization review organization that a specific health care 23 service proposed by a health care provider for a covered person 24 is medically necessary or medically appropriate, and the 25 determination is made prior to the provision of the health care 26 service to the covered person, and, if applicable, includes a 27 utilization review organization’s requirement that a covered 28 person or a health care provider notify the utilization review 29 organization prior to receiving or providing a specific health 30 care service. 31 i. “Utilization review” means a set of formal techniques 32 designed to monitor the use of, or evaluate the medical 33 necessity, appropriateness, efficacy, or efficiency of, health 34 care services. Techniques may include but are not limited to 35 -1- LSB 5949YC (2) 89 ko/rn 1/ 3

H.F. _____ case management, preadmission review, pretreatment review, and 1 prior authorization. 2 j. “Utilization review organization” means an entity that 3 performs utilization review, including a health carrier that 4 meets the requirements established for accreditation set by the 5 utilization review accreditation commission or the national 6 committee on quality assurance and that performs utilization 7 review for the health carrier’s health benefit plans. 8 2. a. A utilization review organization shall not revoke, 9 or impose a limitation, condition, or restriction on, a prior 10 authorization after the date on which a health care provider 11 provides a health care service to a covered person per the 12 prior authorization. 13 b. A health carrier shall reimburse a health care provider 14 at the contracted reimbursement rate for a health care service 15 provided by the health care provider to a covered person per 16 a prior authorization. 17 3. A prior authorization for a specific health care service 18 for a covered person shall be valid for the specific health 19 care service for not less than one year from the date that 20 the covered person’s health care provider receives the prior 21 authorization from a utilization review organization. 22 4. The commissioner may adopt rules pursuant to chapter 17A 23 as necessary to administer this chapter. 24 Sec. 2. APPLICABILITY. This Act applies January 1, 2023, to 25 health benefit plans that are delivered, issued for delivery, 26 continued, or renewed in this state on or after that date. 27 EXPLANATION 28 The inclusion of this explanation does not constitute agreement with 29 the explanation’s substance by the members of the general assembly. 30 This bill is related to reimbursement for health care 31 services provided after receipt of a prior authorization. 32 The bill prohibits a utilization review organization from 33 revoking, or imposing a limitation, condition, or restriction 34 on a prior authorization after the date on which a health care 35 -2- LSB 5949YC (2) 89 ko/rn 2/ 3

H.F. _____ provider provides a health care service to a covered person 1 per the prior authorization. The bill requires a health 2 carrier to reimburse a health care provider at the contracted 3 reimbursement rate for a health care service provided by 4 the provider to a covered person per a prior authorization. 5 “Covered person”, “health benefit plan”, “health care 6 provider”, “health care services”, “health carrier”, “prior 7 authorization”, “utilization review”, and “utilization review 8 organization” are defined in the bill. 9 The bill provides that a prior authorization for a specific 10 health care service for a specific covered person shall be 11 valid for not less than one year from the date that the covered 12 person’s health care provider receives the prior authorization 13 from a utilization review organization. 14 The commissioner of insurance may adopt rules as necessary 15 to administer the bill. 16 The bill applies to health benefit plans that are delivered, 17 issued for delivery, continued, or renewed in this state on or 18 after January 1, 2023. 19 -3- LSB 5949YC (2) 89 ko/rn 3/ 3